Agreement to Mediate Form for CP

U.S. Equal Employment Opportunity Commission
{Accountable EEOC Office}

{Office Address Line 1}
{Office Address Line 2}
{Office City, State Zip Code}
{Office Main Phone}
TTY {Office TTY}
Fax: {Office Main Fax}

AGREEMENT TO PARTICIPATE IN ALTERNATIVE DISPUTE RESOLUTION (ADR)

CHARGE NUMBER: {Truncated EEOC Number}
AGENCY NUMBER: <AGENCY Number>

COMPLAINANT: <Complainant Name>
AGENCY: <AGENCY Name>

This is an agreement by the above parties to participate in mediation in the above referenced complaint. The parties understand that mediation is a voluntary process, which may be terminated at any time. The parties and, if they desire, their representatives and/or attorneys, are invited to attend a mediation session. No one else may attend without the permission of the parties and the consent of the mediator(s).

The mediator(s) will not function as the representative of either party. However, the mediator(s) may assist the parties in crafting a settlement agreement. Each party acknowledges being advised to seek independent legal review prior to signing any settlement agreement. The parties acknowledge that they have received a copy of the Mediation Fact Sheet. The parties acknowledge that the mediator(s) possesses the discretion to terminate the mediation at any time if an impasse occurs or either party or the mediator deems the case inappropriate for mediation.

The parties acknowledge that participation in the scheduled mediation does not constitute an admission by either party of any wrongdoing or of a violation of the laws enforced by EEOC. Furthermore, the Complainant acknowledges that participation in the scheduled mediation by the Agency does not commit the Agency to providing a monetary resolution of the matter.

The parties recognize that mediation is a confidential process and agree to abide by the terms of the attached Confidentiality Agreement. The parties acknowledge that if a settlement is reached as a result of the mediation, the assigned mediator(s) is required to report to EEOC any benefits received. This information is reported only for purposes of providing aggregate data to the EEOC for mediation program evaluation purposes, and the individual terms of the agreement will not be disclosed to the public.
{Signatory’s Digital Signature}{Date of Signature}
Signatory
<Signatory Full Name>
Phone: {Signatory Phone} / Cell Phone: {Signatory Cell Phone}
Date