Oklahoma Department of Corrections
Request for Voluntary Mediation Services

OP-110205 Attachment C

Use this form to request a voluntary mediation process. Your request will be reviewed and you will be contacted and provided instruction for next steps.

Requestor

Name

Work Address

Work Phone Number

Are you Requesting Mediation on behalf of others?

Yes

Will you be an active participant?

Yes

Participants

Participant 1

Name

Please provide the name of participant 1.

Work Phone Number

Work Address

Participant 2

Name

Please provide the name of participant 2.

Work Address

Phone Number

Participant 3

Name

Please provide the name of participant 3.

Work Address

Work Phone Number

Participant 4

Name

Please provide the name of participant 4.

Work Address

Work Phone Number

Conflict Issues

Issues

Briefly describe the issues in the dispute:

Has an internal agency complaint been filed on the issues in dispute?

Yes

If yes, what stage are you at in the complaint process?

Acknowledgements and Attachments

Requestor Acknowledgement

Please type your name in the box below,

acknowledging your intent to request a mediation.

Date Submitted

mm/dd/yyyy

File Upload

Please attach any pertinent information.

Drop your files here

Send me a copy of my responses

Report Abuse

Oklahoma Department of CorrectionsRequest for Voluntary Mediation Services

Requestor

Participants

Conflict Issues

Acknowledgements and Attachments

Oklahoma Department of Corrections
Request for Voluntary Mediation Services