CONFIDENTIAL
Workplace Mediation Referral Form
Please send or email this form to with ‘mediation referral’ in the subject to your HR representative or the Mediation
Scheme coordinator on [email protected].
Office use only
Case Referral
Date referral received
Allocated to mediator(s)
Date and venue of mediation
Date case completed/returned
Outcome of mediation.
Date of one month follow up
Outcome
Date of three month follow up
Outcome
Date of six month follow up
Outcome
Date of twelve month follow up
Outcome
1.
Your details* - Referrer
Please note, that the contents of this referral may be shared with the parties engaged in the Mediation
Department
Full address including postcode
Your name
Position
Your relationship to the parties
Your contact number
Email address
Typical availability
*These details will be used for official purposes
2.
Participants’ details. Please note that we contact all parties by phone in advance of mediation.
Department/section/directorate
Name
Position
Phone numbers (including extensions
and mobiles). Please state preference.
Email address (work and/or personal)
Typical availability
Nature of party’s working relationship
3.
Please provide a brief summary of the situation. Please advise us if the issues are part of a formal
grievance or disciplinary process.
4.
Please provide details of any action taken to date to resolve, investigate of otherwise manage the
situation including outcomes.
5.
Is there anything else happening in the organisation that may be contributing to the conflict? Ie.
Recent structural changes.
Please continue on separate sheets as required.
6.
Please outline your expected outcomes of mediation. These will form our terms of reference.
7.
Please use this space to provide any further information that you feel is relevant to this case. If the
case involves any allegations that are part of a formal grievance or discrimination please provide us
with copies of any relevant reports, policies or Standard Operating Procedures.
Please continue on separate sheets as required.
8.
Logistics
Please include details of the venue for mediation. Please advise us of any specific needs of the parties (this
could include dietary or mobility needs). It will need to be a neutral and private space for the parties to feel
comfortable. See guidelines below.
Where would you like the mediation to take place? (if applicable)
9. Other relevant details. (ensure that all points are met*)
Yes
No
a. Are all parties aware that this case is being passed for mediation?
b. Have the parties been provided with a copy of the TCM Guide to Mediation?
c. Are all parties aware of your expectations of mediation? (Section 6 above)
d. Are all parties aware that they will be contacted by phone prior to mediation
commencing?
e. Is everyone aware that the mediation will take a whole day?
f. Are you aware that the disclosure of the mediation agreement to you or anyone else
is at the discretion of all the parties to the mediation?
* If not all of the points above are not met, we will contact you shortly to discuss options on how to
proceed.
10. To help with the expediency of this referral – can you suggest three possible dates for the mediation?
1.
2.
3.
Please email the completed referral from to your HR representative and/or Mediation Scheme Coordinator to [email protected]
Office use only
Administrative check before proceeding to allocate mediators. This will be done in
conjunction with a follow up phone call to the referrer.
Yes
Actions
See below
Are the referrer’s expectations appropriate to mediation?
Are the mediators aware of all issues?
Are both parties aware that their case has been passed to mediation?
a. Have the parties received the TCM Guide to Workplace Mediation?
Have the parties agreed to mediation?
a. Do the parties understand the Mediation process?
b. Are they available all day?
Have any formal actions been investigated and addressed?
a. Have we seen all documents before continuing?
Have all parties involved in the conflict been taken into account?
a. Has this been thoroughly explored?
Have we addressed all other concerns about whether this should continue to
mediation?
Do you have a suitable local venue for mediation?
Venue Check List (ensure that all points are met)
Yes
No
a. Are there three separate rooms?
b. For discretion, are the rooms located away from the parties’ regular work space?
c. Are the rooms private?
d. Are they within close walking distance from each other?
e. Are they available for the entire day?
f. Will lunch and refreshments be made available?
g. Are there three flipcharts, one for each room?
Follow up, if any, before proceeding: