DOT Form 1050-4 Exit Survey for Mediation Participants

OMB No: 2105-0556

Expiration Date: MM/DD/YYYY

Public Burden Statement

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number.  The OMB Control Number for this information collection is 2105-0556.  Public reporting for this collection of information is estimated to be approximately 1 hour per respondent, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information.  All responses to this collection of information are voluntary.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, U.S. Department of Transportation, Room W56-440, 1200 New Jersey Ave, SE, Washington, D.C. 20590.

Privacy Act Statement

The Privacy Act requires that we provide you with the following information regarding our use of your Personally Identifiable Information. The information on this form is solicited under the authority of 29 C.F.R. Part 1614. The purpose of this form is to inform Complainants about the EEO complaint process. Information provided on this form will be used by the Department of Transportation to determine whether the complaint was timely filed, whether the claims in the complaint are within the purview of 29 C.F.R. Part 1614, to provide a factual basis for investigation of the complaint, and to ensure that the proper processes were followed. Formal complaints of employment discrimination must be in writing, signed by the Complainant (or attorney representative), and must identify the parties and action or policy at issue. Failure to comply may result in the Department of Transportation dismissing the complaint. It is not mandatory that this form be used to provide the requested information.

EXIT SURVEY FOR

MEDIATION PARTICIPANTS

NOTE: Upon completion of the mediation session, the parties are encouraged to complete this survey.

Date(s) of session: _____________________________________________

Session location: _____________________________________________

Mediator(s) name: _____________________________________________

_____________________________________________

1. What was your role in the case?

1. Aggrieved person

2. Complainant

3. Agency Official (respondent)

4. Manager/Supervisor/Team Leader (respondent)

5. Representative for aggrieved person/complainant

6. Representative for management (respondent)

2. What is your grade level? ____________________

3. If you had a representative during the mediation, was your representative a:

(a) Fellow employee

2. Attorney

3. Other (please specify): ____________________________

4. Did not have representative

4. What was the basis(es) of the EEO complaint in this case? Circle all that

apply.

(1) Race (5) Disability (9) Sexual orientation

(2) Color (6) Religion (10) Retaliation

(3) National origin (7) Age (11) Pregnancy

(4) Sex (8) Genetic Information Discrimination Act

of 1978

5. On what date did the dispute begin? _________________________

6. Please circle or describe the cause of the action of the dispute.

(a) Promotion

2. Non-selection

3. Performance Rating

4. Disciplinary Action

5. Sexual Harassment

6. Other (please describe): ________________________________________

7. Please describe the relief requested in the dispute prior to mediation.

______________________________________________________________________________________________________________________________________

8. How long was this mediation session? __________(number of hours)

9. During the mediation, did you learn about the other party’s view?

(a) Yes

(b) No

10. During the mediation session, did the other party learn about your view?

(a) Yes

(b) No

11. Did the mediation result in a settlement agreement?

(a) Yes – Skip to question 13

(b) No

(c) Partially

12. If the mediation failed to result in a settlement agreement or resulted in a partial settlement, were there positive outcomes (such as, a better understanding of the issue or a better communications between the parties) that made it worthwhile?

(a) Yes (please specify): ______________________________________________

__________________________________________________________________

__________________________________________________________________

(b) No

13. Thinking about your most recent mediation session, please assess the mediator’s performance in the following areas:

(Circle one number on each line to indicate your rating)

The mediator….. Poor Fair Good Excellent

a. inquired into facts of the complaint impartially	1	2	3	4
b. understood issue(s) of the complaint	1	2	3	4
c. assisted the parties with generating realistic options	1	2	3	4
d. clarified the issue(s) of the complaint	1	2	3	4
e. gained the confidence and trust of the parties	1	2	3	4
f. handled emotional issues satisfactorily	1	2	3	4
g. maintained effective manner (calm, sensitive, empathic, flexible, purposeful)	1	2	3	4
h. inspired confidence in the mediation process	1	2	3	4
i. honored confidentiality	1	2	3	4

14. Thinking about your experience with mediation overall, please indicate your feelings about the following statements:

(Circle one number on each line to indicate your rating)

	Strongly Disagree	Somewhat Disagree	Neither	Somewhat Agree	Strongly Agree
a. You received sufficient information about mediation	1	2	3	4	5
b. You were comfortable with the session environment	1	2	3	4	5
c. The mediation was fair	1	2	3	4	5
d. Your level of participation in the mediation was sufficient	1	2	3	4	5
e. Your views were addressed satisfactorily	1	2	3	4	5
f. The mediator helped clarify your goals	1	2	3	4	5

15. Have you ever been through the EEO complaint process before?

(a) Yes

(b) No – Skip to question 20

16. How many times have you been through the EEO complaint process? ______

17. Please circle the highest level of any of your prior EEO complaint activity:

(a) Pre-complaint (EEO counseling or mediation)

2. Formal Complaint

3. Final Agency Decision

4. EEOC Hearing

5. Court Decision

18. How did time in mediation relate to time in the EEO complaint process?

Mediation took: (a) much less time

(b) less time

(c) the same amount of time

(d) more time

(e) much more time

19. Did mediation save you resources when compared to pursuing the complaint through the EEO complaint process?

(a) Yes

(b) No

20. Have you participated in the Mediation Program before?

(a) Yes

(b) No

If yes, how many times? __________

21. Would you participate in mediation again?

(a) Yes

(b) No

22. Do you have additional comments or suggestions to improve the Mediation Program?

___________________________________________________________________

___________________________________________________________________

Thank you!