Santa Clara — CV-5005*

Source: https://santaclara.courts.ca.gov/system/files/forms/cv-5005_rem.pdf

SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA ADR PROVIDER’S STATEMENT/CIVIL DIVISION PLEASE MAIL WITHIN 10 DAYS OF THE COMPLETION OF THE ADR PROCESS TO: LAURIE MIKKELSEN, ADR ADMINISTRATOR SANTA CLARA COUNTY SUPERIOR COURT 191 N. FIRST STREET, SAN JOSÉ, CA, 95113 OR FAX TO 408-882-2595 OR EMAIL ADR@SCSCOURT.ORG Please complete this statement without breaching confidentiality.

Case Name: Case No:

Your Name: Your Phone Number:

ADR Process: Mediation Neutral Evaluation Other (specify):

Type of case: Banking Health Care Partnership Disputes Business/Contract Housing Personal Injury Civil Rights Intellectual Property Probate - Wills Construction Insurance Professional Negligence Defamation Labor - Employment Real Estate Disabilities Landlord/Tenant Securities Elder Issues/Abuse Medical Malpractice Tax Environment Neighborhood Other (specify)

Preparation time: hours Total length of ADR sessions hours No. of sessions: Total fee for ADR process for all parties (include any charges for administration, preparation, travel, etc.): $

How did the case resolve? Full resolution Partial resolution No resolution Other (specify):

The case did not fully resolve because: Additional discovery was necessary An essential party did not participate One or more of the parties did not have authority to settle The parties reached an impasse Other (specify):

For Mediators Only: Was your primary style in this case Facilitative Directive/Evaluative Did the parties or counsel ask about the law? Yes No Did you discuss the relevant law? Yes No

For Neutral Evaluators Only: Following your evaluation did you: Conduct a mediation? Yes No Conduct a settlement conference? Yes No Provide case management assistance? Yes No Specify:

Did you give evaluation forms to the parties and counsel? Yes No

Comments on any of the above matters or on administration of the ADR program:

ADR PROVIDER’S STATEMENT/CIVIL DIVISION

CV-5005 REV. 11/8/2019