Rules and Procedures for the Dispute Resolution Act.
Chapter 37, App.
Appendix D. Record of Termination.

1. 1. Nature of Dispute (briefly describe)

   ____________________________________________________________________________________________
   ____________________________________________________________________________________________
   ____________________________________________________________________________________________

2. 2. Relationship of Parties (briefly describe) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

3. 3. Persons, other than the parties, present at mediation (name, address, telephone, relationship)

   ____________________________________________________________________________________________
   ____________________________________________________________________________________________
   ____________________________________________________________________________________________

4. 4. Indicate at what stage the mediation session terminated:

   ____ Introduction ____ Information exchange Negotiations ____ Agreement

5. 5. Comments

   ____________________________________________________________________________________________
   ____________________________________________________________________________________________
   ____________________________________________________________________________________________

6. 6. If there is a referral to another agency, indicate which party was referred and to what agency

   ____________________________________________________________________________________________
   ____________________________________________________________________________________________
   7. Describe follow-up plan

   ____________________________________________________________________________________________
   ____________________________________________________________________________________________

7. 8. Recommendations and Remarks

   ____________________________________________________________________________________________
   ____________________________________________________________________________________________
   ____________________________________________________________________________________________

   ______________________________________ Mediator

If a mediation session was not held, indicate whose absence was responsible: (a.) Initiating party, (b.) responding party, or (c.) both parties. _________

If a mediation session was held, please complete the remainder of this record.

Adopted April 8, 1986; Revised April 20, 1989.