The Ohio State University Logo

Mediation Request

Please provide your contact information.

Enable additional features by logging in.

Your full name:

Your position/title:

Your phone number:

Your OSU email address:

Email address must be of a valid format.

Your address:

Time of incident:

Specific location:

Parties

Please provide identifying information for all of the individuals who should participate in the mediation.

Involved party 1

Name or Organization

Student ID Number

Phone number

Email address

Hall/Address

Questions

Please provide a brief summary of the conflict you hope to resolve with mediation.(Required) This field is required.

Have you discussed using the mediation program with all of the involved individuals?(Required)

Yes No

This field is required.

If not, please list the individuals who you have not spoken with or who have shown reluctance to participate in a mediation. This field is required.

Does any party have concerns for their own safety?(Required)

Yes No

This field is required.

Have there been any instances or threats of physical violence?(Required)

Yes No

This field is required.

We usually schedule mediations Monday through Friday after 6 PM. Please list days of the week that are NOT available for one or more parties.

Monday Tuesday Wednesday Thursday Friday

You must make at least one selection.

Is there anything else you would like to share that might help us schedule your mediation? This field is required.

Who referred you to the Mediation Program? This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Submission

Email me a copy of this report