Denver Employee Mediation Form
Requester Information
Name
Job Title
Phone
Agency or Division
Preferred Method of Email Communication
Denvergov
Personal
Denvergov Email
Personal Email
Primary Party is Requester
Primary Party Information
Name
Job Title
Working relationship to the requester (e.g. co-worker, supervisor)
Email
Phone
Do you need to add Party 1 Information?
Yes
No
Other Party 1 Information
Name
Job Title
Working relationship to the requester (e.g. co-worker, supervisor)
Email
Phone
Do you need to add Party 2 Information?
Yes
No
Other Party 2 Information
Name
Job Title
Working relationship to the requester (e.g. co-worker, supervisor)
Email
Phone
Do you need to add Party 3 Information?
Yes
No
Other Party 3 Information
Name
Job Title
Working relationship to the requester (e.g. co-worker, supervisor)
Email
Phone
Please provide a summary of the conflict and what you would like to resolve through mediation.
Does the other party know you are requesting mediation?
Yes
No
Do you consent to having Community Mediation Concepts inform your HR representative of the general nature of your mediation request so they can assist you?
Yes
No
Optional Attachments:
Contact Information