Form 3320-0004(2) Mediation Services - Practitioner Questionnaire (Paper)

OMB Number: 3320-0004
Approval Expiry Date: XX/XX/XXXX

Mediation Practitioner Questionnaire
(Agreement Seeking)
The U.S. Institute for Environmental Conflict Resolution evaluates all of its projects and cases. You have
served as a mediator or facilitator in one of these projects/cases, and the Institute requests your assistance with
this evaluation. Your responses will be part of the Institute’s ongoing evaluation effort, and the data compiled
will provide much-needed information that will be used to improve our programs and services. The average
estimated reporting burden for this questionnaire is 30 minutes. This estimate includes time for reviewing the
instructions, gathering the data needed, completing, and reviewing the questionnaire. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to the Institute. The Office of Management and Budget (OMB) number that is displayed
on the cover is currently valid and authorizes this collection of information.

1. What was the application of the collaborative process in this case or project?
OUT OF THE FOLLOWING LIST, PLEASE CHECK THE MOST APPROPRIATE BOX.
Check only one
F

a. Policy development

F

b. Planning

F

c. Siting and construction

F

d. Rulemaking

F

e. License and permit issuance

F

f. Compliance and enforcement action

F
F

g. Implementation/monitoring agreements
h. Other (please specify): _________________________

2. Please identify the geographic location(s) for this case: (Check all that apply)
F AL

F DE

F IN

F MA

F NE

F NC

F RI

F VT

F AK

F DC

F IA

F MI

F NV

F ND

F SC

F VA

F AZ

F FL

F KS

F MN

F NH

F OH

F SD

F WA

F AR

F GA

F KY

F MS

F NJ

F OK

F TN

F WV

F CA

F HI

F LA

F MO

F NM

F OR

F TX

F WI

F CO

F ID

F ME

F MT

F NY

F PA

F UT

F WY

F CT

F IL

F MD

F Regional

F National

F International

3. Please identify the central issues to this collaborative process: (Check all that apply)
F Agriculture
F Air Quality
F Archeology or Historic Preservation
F Coastal Zone or Marine Management
F Ecosystem Management
F Endangered Species and/or Critical Habitat
F Energy
F Forest and Timber Management
F Land Use and Urban Development
F Mining
F Native American, Alaska Native, Native Hawaiian Issues
F Parks and Refuges
F Recreational Use and Access
F Solid or Hazardous Waste
F Transportation
F Watershed/River Basin Management
F Water Quality
F Water Supply
F Wildlife Management

2

4. How many sessions (including conference calls and meetings) were held in conjunction with
this particular process?
_____

Number of sessions

5. Estimate the number of hours you and the other mediators/facilitators devoted to this
case/project:
_____

Total hours

6. What was the total value of the contract for all mediator/facilitator services devoted to this
case/project?
$_________

Total contract value

7. What was the total number of months or years in which you were actively working on this
case/project:
0 - 6 months

7 - 12 months

1 - 2 years

3 - 5 years

More than 5
years

F

F

F

F

F

Rating Scale
0

1

Not at all
difficult

2

3

4

5

6

7

8

9

Moderately
difficult

10
Extremely
difficult

8. Using the scale above, please rate the difficulty of meeting the following objectives:
Rating
_____

a. The difficulty of developing and implementing an effective collaborative
process for this case or project compared to similar cases with which you are
familiar or have been involved.

_____

b. The difficulty participants had in reaching agreement, compared to similar
cases with which you are familiar or have been involved.

3

9. Please characterize the participants by doing the following:
Please indicate THE NUMBER of participants that were included in the process within each of
the given categories (e.g., if 2 separate participants represented the state, place a ‘2’ in the box
for ‘State Government’).
Number of
participants
included in the
process
a. Federal Government

______

b. State Government

______

c. Local/Regional Government

______

d. Tribal Government

______

e. Environmental/Conservation

______

f. Recreational

______

g. Industrial/Resource Extraction

______

h. Business/Commercial

______

i. Community or Private Citizen (e.g., neighborhood association, local
resident)

______

j. Special Advocacy Interests (Please specify): __________________

______

k. Other (Please specify): ___________________________________

______

10. What was the greatest challenge that YOU faced as the mediator/facilitator to initiating an
effective collaborative process (including barriers to participants’ ability to participate)?
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

4

Rating Scale
0

1

2

3

4

Do not agree
at all

5

6

7

8

9

Moderately
agree

10
Completely
agree

11. Using the above scale, please rate your agreement with the following statements:
IF THE QUESTION DOES NOT PERTAIN TO THE CASE/PROJECT, PLEASE CHECK N/A (“NOT APPLICABLE”).
Check if
N/A

Rating
____

a. On reflection, I feel I was the right mediator/facilitator to guide this
process.
b. If needed, resources were available to obtain the relevant
expertise/information for this case or project
c. Experts were used to educate participants in the collaborative process
on the relevant issues

F

____

F

____

F

____

d. In general, the relevant information was understood by the participants

F

____

e. Participants worked to ensure agreement on the meaning of the
relevant information

Rating Scale
0

1

Not at all
problematic

2

3

4

5

6

7

8

9

Moderately
problematic

10
Very
problematic

12. Using the scale above, please rate the following:
Extent to which
the following was
problematic
a. Some participants lacked the skills required for participating
____
effectively in the collaborative process
____

b. Some participants lacked the time required for participating effectively
in the collaborative process

____

c. Some participants lacked the financial resources required for
participating effectively in the collaborative process

____

d. Some participants did not have access to the information required for
participating effectively in the collaborative process

____

e. Some organizations or interests that should have been included were
absent from the collaborative process

5

13. Did the process conclude in an “agreement”? The term “AGREEMENT” applies to the written
or unwritten agreement reached by participants in the process, including plans,
proposals/recommendations, procedures, collaborative decisions to work together and settlements.
CHECK THE MOST APPROPRIATE BOX ONLY AND PLEASE USE THE SPACE PROVIDED TO EXPAND ON
YOUR ANSWER. TO ANSWER THIS QUESTION, THINK ABOUT WHAT IT WAS THAT THE GROUP WAS
CHARGED TO COME UP WITH AT THE END OF THIS COLLABORATIVE PROCESS.
CHECK
ONLY ONE

F

Agreement reached on all key issues

F

Agreement on most key issues

F

Agreement on some key issues

F

No agreement on any key issues, but
progress was made towards addressing
the issues or resolving the conflict.

F

No agreement, we ended the process
without making much progress.

Use the space below if you
would like to elaborate on your
response:

14. What form did the “agreement” take?
F

a.

Written

F

b.

Oral

F

c.

Combination

F

d.

Did not reach agreement

15. Please tell us how we can obtain a copy of the agreement.
F

a. I will email a copy of the agreement using the email address provided on the
cover letter attached to this survey.

F

b. I will attach a copy of the agreement with this evaluation questionnaire.

F

c. I would recommend that you contact
to obtain a copy of the final agreement.

__________________________

Please provide contact information, if available to you: _______________
F

d.

Not applicable/available (e.g., not releasable, no written agreement)

6

Rating Scale
0

1

2

Do not agree
at all

3

4

5

6

7

8

9

Moderately
agree

10
Completely
agree

16. Using the above scale, please indicate your level of agreement with the following statements
about the completeness of the agreement: CHECK “N/A” IF AN ITEM IS NOT APPLICABLE TO THE
CASE.
Check Rating
if N/A
____ a. Key interests were addressed in the agreement.
F
F

____

b. The agreement addresses the resources needed for its
implementation.

F

____

c. Legal requirements have been addressed. F Check if "Don't Know"

F

____

d. The agreement took full advantage of relevant information
(scientific, economic, cultural, legal, etc.).

F

____

F

____

F

____

F

____

e. The agreement identifies responsibilities and roles for
implementation.
f. The agreement contains provisions for monitoring implementation
and standards for measuring accomplishments.
g. Agreement includes conditions under which the participants will
reconvene.
h. The agreement provides workable means for adapting to important
unanticipated circumstances or changes in conditions.

17. What was the greatest challenge that YOU faced as the mediator/facilitator to reaching
agreement?
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

7

18. Reflecting on the case or project, are there any lessons that should be recorded? WE ARE
PARTICULARLY INTERESTED IN KNOWING IF THERE WERE PARTICULAR EVENTS OR FACTORS THAT
AFFECTED SUCCESS IN THIS CASE OR PROJECT. IF APPLICABLE, PLEASE ALSO TELL US ABOUT KEY
INNOVATIVE OR CREATIVE THINGS IN THE AGREEMENT THAT MIGHT NOT HAVE HAPPENED IN THE
ABSENCE OF AN AGREEMENT.

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

19. The evaluation also asks participants for information about the case/project. Please
provide the following information about the participants to help us contact them for the
evaluation.

Name of Organization: ____________________________________________________
Affected interest/concerned interest represented: ________________________________
Representative at the table:

__________________________________________

Address: _______________________________________________________________
Phone: _______________________________ Email: ___________________________

YOU LIKELY ALREADY HAVE THIS INFORMATION IN A TABLE OR SPREADSHEET, AND YOU ARE
WELCOME TO ATTACH THAT INFORMATION TO THIS SURVEY OR EMAIL IT TO [email protected].

MANY THANKS FOR TAKING THE TIME TO PROVIDE YOUR FEEDBACK.

8