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This is a sample Intake Sheet from the U.S. Postal Service

USPS REDRESS Mediation - Intake/Referral Form

1. Counselee:

Case No:
Tour: Work Hours:
Off Days: Pay Loc:
Duty Station: Phone no:
Complete only if changed
Home Address:


Phone: Best times to call:

If REDRESS is Declined, Reason:

Complete only if not explained on written complaint

2. Brief Description of Issues and Basis (es):

Complete if not listed on written complaint

3. Counselee's representative of choice and their status: (e.g., union steward, lawyer, friend)

Name and Position:
Duty Station/Address:
Telephone #: Fax #:

4. EEO Personnel has read or given the statement on the reverse side to the counselee:

YES NO

5. Counselee has been told the use of mediation is voluntary and he/she is not required to use mediation in order to resolve the dispute:

YES NO

6. Counselee has been advised that even though he/she has requested mediation, that request may be declined by the Postal Service:

YES NO

Request dates for next three weeks

7. Counselee available dates for mediation:

8. Responsible Management Official:

Name and Position:
Duty Station/Address:
Telephone #: Fax #:

9. If the stated issues in item #2 include sexual harassment, you must find out whether the Counselee has previously contacted any member of postal management to report the harassment. Counselee _______ HAS ________ HAS NOT reported harassment to management.

10. If the stated issued in item #2 include sexual harassment, follow REDRESS protocol with the District HR Manager to determine whether the complaint will be mediated.

Date protocol was completed and mediation request for sexual harassment issues was accepted: ______________________

11. Management Official available dates:

12. Person who will attend the mediation along with the Management Official, if any:

Name and Position:
Duty Station/Address:
Telephone #: Fax #:

13. Mediation Conference:

Location:
Date/Time:
Conference Room:
Contact Person at Facility:

14. Special needs or accommodations:

15. Mediation must be held no later than __________________ (90 Days from initial contact) in order not to violate legal timeliness.

16. Date the Counselee agreed to mediation: ______________ Date Scheduled: ___________

17. Mediation due: __________ (14 days) ___________ (21 days) ___________ (30 days)

18. Mediator Assigned: _____________________________ Type: ______________________