Fillable 300-00019 - Mediator Report Form

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300-00019 - Mediator Report Form

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300-000019 – Alternative Dispute Resolution Report (10/2015) Page 1 of 1
STATE OF VERMONT
SUPERIOR COURT
ENVIRONMENTAL DIVISION
Vermont Unit
Docket No.:
ALTERNATIVE DISPUTE RESOLUTION REPORT
Report due from mediator within 15 days of completion of mediation
Date of ADR Session: _______________ State Time: _______________ End Time: _______________
1. Please indicate the names and addresses of all persons participating in the ADR Session. If any party is a
corporation or other entity, please indicate the name and title of the representative. Identify with an
asterisk the representative of each party who had decision-making authority. (Attach additional sheets, if
necessary.)
Name
Representative & Title
If Applicable
Mailing Address
Appellant/Plaintiff
Appellant/Plaintiff’s Counsel
Appellee/Defendant
Appellee/Defendant’s Counsel
Municipality/State
Municipality/State’s Counsel
Interested Parties/Other
2. Were all appropriate parties in attendance? ☐ Yes ☐ No
If No, who failed to appear? _______________________________
Please summarize any substitute arrangement made regarding attendance at the ADR Session.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
3. Was full or partial settlement reached at the session? ☐ Yes ☐ No
If Yes, please summarize and append any agreement of the parties.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Dated
_____________________________ ___________________________________
Mediator’s Signature
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300-00019 - Mediator Report Form

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Completed 3 July 2020

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