LEA Mediation Information Form

Please complete this form. The Mediation Case Manager will be in contact with you once submitted.

Name*
First Last
Title
Email*
Phone
Student Name*
First Last
Student's Exceptionality
Select the primary exceptionality of the student.
Mediation File Number*
(e.g., 12345-00-11)
Please choose which format you prefer for the mediation session.
Facilitative and Evaluative Mediation Styles
See our Styles of Mediation page (https://odr-pa.org/mediation/styles-of-mediation/) for more information between the two types of mediation.
- Facilitative Mediation (In-person or virtual)
- Evaluative Mediation (virtual only)
Authorization of Resources*
In the event the chief school administrator is not attending the scheduled mediation session, a school official will be designated with the authority to commit resources to reach an agreement satisfactory to both parties. The mediator will not begin the session without this person present. If there are any changes to the Authorization of Resources after filling out this form, please contact ODR. **ODR will no longer provide a separate Authorization of Resources form.
First Last
Authorized Person's Title/Position*
Please write in the name, title, phone number, and email address of all participants you will be bringing to mediation. It is your responsibility to share (via email) this list of participants with the parent(s) as well. **If you make changes to the list of participants, please notify both ODR and the parent(s) via email. Any questions or concerns regarding the participant list must be discussed with the parent(s).
To support a productive process, ODR suggests each party brings no more than three participants; however it is up to you to determine who will participate in the mediation.
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LEA Mediation Information Form

LEA Mediation Information Form

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