OREGON JUDICIAL DEPARTMENT
Court-Connected Mediator Continuing Education Reporting Form
Please note: a modern, DOM-aware browser running Javascript must be used for this form to function properly. If nothing is displayed below this message, please enable Javascript in your browser settings and refresh the page. If it still does not work, you will need to use a more up to date, fully functional browser.
03/10/2014
Contact Information
:
*Required Field
First Name:
*
Last Name:
*
Counties You Serve
(Select all that apply):
Baker
Benton
Clackamas
Clatsop
Columbia
Coos
Crook
Curry
Deschutes
Douglas
Gilliam
Grant
Harney
Hood River
Jackson
Jefferson
Josephine
Klamath
Lake
Lane
Lincoln
Linn
Malheur
Marion
Morrow
Multnomah
Polk
Sherman
Tillamook
Umatilla
Union
Wallowa
Wasco
Washington
Wheeler
Yamhill
*
(HINT: Hold down the Ctrl key to
select more than one county.)
Address (optional):
Telephone (optional):
Fax (optional):
E-mail (optional)
I am a (check all that apply):
*
General Civil Mediator (FED, small claims, circuit court)
Domestic Relations Custody & Parenting Mediator
Domestic Relations Financial Mediator
Continuing Education Program:
Sponsor:
Title:
*
Date(s):
*(MM/DD/YYYY)
Location:
Total Number of hours:
*
Type of Program:
*
Live program (conference, seminar, presentation, discussion, brown bag or salon)
Audio, video or web-based program (conference, seminar, presentation, or discussion)
Receiving supervision as part of a training mentorship
Formally debriefing mediation cases with supervisor and/or mediator colleagues
Lecturing or teaching qualified continuing education course
Reading, authoring or editing written materials with significant mediation content
This Program Included _________ Hours Covering (complete all that apply):
General Mediation
Custody and Parenting Issues
Financial Issues
Mediation Confidentiality
Mediation Ethics
Word Validation:
Type the characters you see in the picture below. Letters are not case-sensitive.
Please print this form for your records prior to submitting.
