Fillable Court-Connected Mediator Application Form oregon

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Court-Connected Mediator Application Form oregon

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P a g e | 1 of 7 Mediator Application Form
CIRCUIT COURT OF THE STATE OF OREGON
Fourth Judicial District
Court-Connected Mediator Application Form
Qualifications for mediators are based upon the Oregon Judicial Department Court-Connected Mediator
Qualifications Rules, issued as Chief Justice Order (CJO) No. 05-028, effective August 1, 2005.
For more information regarding the CJO go to:
http://www.courts.oregon.gov/courts/multnomah/programs-services/Documents/
Mediation_CJO_05028.pdf
Guidelines for Mediator Applicants can be found at:
https://www.courts.oregon.gov/courts/multnomah/programs-services/Documents/
Mediation_GuidelinesForMediatorApplicants.pdf
Instructions for submitting the completed form are at the bottom of the last page of this form.
Please note: Approved applications will appear on the court website as public information.
General Information
Applicant’s Last Name:
First Name, Middle Initial:
Title:
Mailing Address:
Business Phone (1):
Business Phone (2):
Fax:
E-Mail (1):
E-Mail (2):
Website:
I Am Applying To Be A:
General Civil Mediator Yes No
Probate Mediator Yes No
Domestic Relations Custody and Parenting Mediator Yes No
Domestic Relations Financial Mediator Yes No
I adhere to the following organization’s code(s) of professional ethics (e.g. OMA, OSB, ACR, AAA, etc.):
I certify that I include in my opening remarks to the parties the required information specified in
Section 1.4(3) of the CJO. (Initials)
P a g e | 2 of 7 Mediator Application Form
Current Employment Information
Professional Memberships
It is required that you attach diplomas, certificates, or other forms of verification for the sections of
the application below that contain an asterisk.
* Basic Mediation Training (verifying certificates or diplomas required)
Basic Mediation Training (Minimum required: 30 hours) [Sections 2.1(1)(a), 2.2(2)(a), 2.3(2)(a), & 3.2]
Indicate the description, trainer(s), number of hours, and dates. If you have not had Basic Mediation
Training, describe substantially similar training or education. (Please note that experience as a mediator
does not constitute “training.”)
* Court System Training (verifying certificates or diplomas required)
Describe your court system training. (Minimum required: 8 hours) [Sections 2.1(1)(b), 2.2(2)(c),
2.3(2)(d), & 3.5] Indicate the description, trainers(s), number of hours, and dates.
If you have not had 8 hours of Court System Training, describe substantially similar training or education.
Indicate the trainer(s), number of hours, and dates.
Mediation Experience (Only General Civil Mediator and Probate Mediator
applicants complete the next two boxes.)
Describe your observations of 3 actual mediations [in accordance with Section 2.1(2)].
P a g e | 3 of 7 Mediator Application Form
Describe your experience mediating or co-mediating where you were observed by a qualified supervisor in
3 court-connected civil cases [in accordance with Section 2.1(2)] .
Probate Mediators (Only Probate Mediator applicants complete the next box.)
I am applying to be a probate mediator (conservatorship/guardianship, estate disputes,
and/or trust matters). I meet the qualifications set forth in SLR 12.045(8).
Please describe how you qualify: (e.g. attorney with five years relevant experience; individual with special
skills and training in administration of estates, trusts or protective proceedings; or mediator training)
I have completed the Multnomah County Probate Department mediation training.
_______ Initials _________________ Date of Training
Domestic Relations Mediators (Both Domestic Relations Custody and
Parenting Mediator and Domestic Relations Financial Mediator applicants complete the
next 3 boxes.)
*Education (verifying certificates or diplomas required)
Enter your Law, Master’s, or Doctorate degree in a specific field. [Sections 2.2(1)(a-c) & 2.3(1)] Include
the institution’s name, dates attended, and degrees awarded.
If you have none of the above, but have a bachelor’s degree and 7 years of relevant experience, enter your
degree, the institution’s name, dates attended, and degrees and date awarded. Then describe your 7 years
of relevant experience. [Sections 2.2(1)(d) & 2.3(1)]
P a g e | 4 of 7 Mediator Application Form
*Domestic Relations Custody and Parenting Mediator Training
(verifying certificates or diplomas required) (Minimum required: 40 hours.) [Sections 2.2(2)(b), 2.3(2)(b) &
3.3] Indicate the description, trainer(s), number of hours, and dates.
Domestic Relations Custody and Parenting Mediator Experience.
(Only Domestic Relations Custody and Parenting Mediator applicants complete this box.)
(Please describe your participation in at least 20 domestic relations cases, with 100 hours supervised or
co-mediated with qualified supervisor; minimum 10 cases/50 hours custody and parenting mediation; or
at least 2 years full-time experience as described in Section 2.2(3). Include name(s) or supervisor(s)
and/or co-mediator(s).
* Domestic Relations Financial Mediator Training
(Only Domestic Relations Financial Mediator applicants complete the next 3 boxes.)
(verifying certificates or diplomas required) (Minimum: 40 hours domestic relations financial issues
training) [Sections 2.3(2)(2) & 3.4] Indicate the description, trainer(s), number of hours, and dates.
P a g e | 5 of 7 Mediator Application Form
Domestic Relations Financial Mediator Experience.
(Please describe your participation in at least 20 domestic relations cases, with 100 hours supervised or
co-mediated with qualified supervisor; minimum 10 cases/50 hours domestic relations financial
mediation; or at least 2 years full-time experience as described in Section 2.3(3). Include name(s) or
supervisor(s) and/or co-mediator(s).
Insurance for Domestic Relations Financial Mediators
I certify that I have in effect, and shall maintain during my court-connected mediator listing, malpractice
insurance or self-insurance with comparable coverage as required by Section 2.3(7).
Initials
Insurance Company
Other Mediation Training (All applicants complete the next 3 boxes.)
Enter description(s) of specialized or advanced mediation training.
Other Experience
Describe any other relevant experience.
Describe any special skills or experience you have (e.g. second language proficiency, cultural
sophistication, non-mediation related licenses or skills, other relevant education, etc.).
P a g e | 6 of 7 Mediator Application Form
All Applicants complete the next sections, only as relevant to your practice.
Indicate with a checkmark in the boxes below the types of cases you are willing and have experience to
mediate. No checkmark will indicate you are not willing to mediate those types of cases. Indicate in the
second column the number of that type of case you have mediated. If any explanation is necessary, use the
Comments column.
Civil Types of Cases Mediated
Type of Case
Mediate?
No of Cases
Business/Commercial
Yes
Contract
Yes
Employment
Yes
Small Claims
Yes
Landlord-Tenant Residential/
Commercial
Yes
Real Property
Yes
Tort
Yes
Construction
Yes
Professional Negligence
Yes
General Negligence
Yes
Other
Yes
Probate Types of Cases Mediated
Type of Cases
Mediate?
No of Cases
Comments
Estate Disputes
Yes
Trust Matters
Yes
Guardianships/
Conservatorships
Yes
Domestic Relations Types of Cases Mediated
Type of Case
Mediate?
No of Cases
Comments
Adoption (including open
adoption)
Yes
Custody
Yes
Dissolution
Yes
Domestic Partnership
Yes
Domestic Violence
Yes
Filiation/Paternity
Yes
Grandparents Disputes
Yes
Parenting Time
Yes
Support Disputes
Yes
UCCIA
Yes
Compensation Information
Describe Fees.
Are you willing to consider pro bono requests?
Yes
No
P a g e | 7 of 7 Mediator Application Form
Oath
I hereby certify that I have reviewed and, if selected, will comply with the Oregon Revised
Statutes, Uniform Trial Court Rules, and Supplemental Local Rules for Multnomah
County that pertain to civil case mediation. I affirm that I have reviewed the August
2005, Chief Justice Order No. 05-028, describing the Oregon Judicial Department Court-
Connected Mediator Qualifications Rules and that the above information is a true and
accurate reflection of my qualifications as a mediator as outlined in that CJO. I
acknowledge that my information may be verified, and that any references and/or
programs listed above may be contacted. I expressly approve such investigation, and
consent to the release of information about me from any relevant source. I agree to fulfill
the continuing education requirement for court-connected mediators [Section 2.1(3),
2.2(4), 2.3(4), & 3.6] and all other requirements specified in the CJO. I will keep the court
informed of any changes in my contact information, license status, or qualifications to be
listed as a mediator.
Signature Date
Sign with an electronic signature per UTCR 21.090(2)
INSTRUCTIONS FOR SUBMITTING COMPLETED FORM
After the form has been completed, click the button bellow to e-mail this PDF form to the court.
If you don’t have the ability to e-mail using the button below, you will need to save
the PDF to your computer, then e-mail it manually as an attachment to:
mediation.coordinator@ojd.state.or.us
Retain a copy for your records if you desire. Having this form saved to your computer will expedite your ability to
update information as required by the CJO.
Questions? Call the mediation coordinator at 503-988-3318 or e-mail mediation.coordinator@ojd.state.or.us
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Completed 6 December 2019

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