Disput. Info. Form

Disputant Information Form

Each disputant must complete THEIR OWN disputant information form. We cannot process your mediation until we have a DIF from each disputant.

Make sure that you contact your area coordinator to let them know you want a mediation if you live in the residential halls if you are thinking of moving. If you are not planning on moving you do not need to contact them.

Link to hard copy

Complete only those fields which are relevant.

Your Name

Race/Ethnicity

(Optional)

Gender

(Optional)

Age

Where you live (list off-campus or your particular hall)

Phone Number

Email Address

Are you willing to allow the mediators to view your roommate contract?

Yes No

Times Available for Mediation (please include date of month and time of day):

Day of Week	Time
Monday	(5:30 pm - 8:30 pm)
Tuesday	(5:30 pm - 8:30 pm)
Wednesday	5:30 pm - 8:30 pm
Thursday	(5:30 pm - 8:30 pm)
Saturday	(10:00 am - 5:00 pm)

Name of Disputant 2:

Name of Disputant 3:

Name of Disputant 4:

Your Relationship to Disputant 2:

Your Relationship to Disputant 3:

Your Relationship to Disputant 4:

Brief Description of Conflict:

Your Desired Outcome of the Situation:

Please encourage all other disputants to complete this form ASAP. We cannot schedule your mediation until we have one from each disputant.