Mediation Request Form

Name*

Northwestern email address*

Role at Northwestern (select all that apply)*

Select or enter value

Primary department or unit at Northwestern*

Names of the other person/persons involved and their role.*

Is the other person/persons involved interested in mediation?*

Select

Please provide a brief description of the issue for which you are seeking mediation including the individuals involved, the primary issue(s), and anything else you feel is important for us to know.*

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