Candidates Name: QAP Application Questionnaire

Transcription

1 Candidates Name: QAP Application Questionnaire

2 General Information Name: Company: Title: Telephone: Website: Address: Dear Applicant, Thank you for choosing to apply to our qualifying assessment program (QAP) for IMI certification. We look forward to working with you as you endeavour to attain to this valuable international certification for mediation practitioners. This questionnaire will assist us to set you on the right pathway to achieve your goal. Should you need any assistance in completing this questionnaire please contact: Synopsis of your professional background: This questionnaire should be completed and signed by the applicant themselves. Please also attach a copy of your current curriculum vitae when returning the completed questionnaire along with evidence of evaluation and feedback for at least three cases (see page 3). You will receive notification on acceptance to the QAP or advice on further steps needing to be taken before being accepted within 7 days of our receiving this application questionnaire. Please scan the completed document and attachments and it to info@beyondconflict.ie or post it to 1 Oughill, Redcross, Co. Wicklow. Please note we cannot take responsibility for postal applications being delayed or lost in transit.

3 Mediation Experience In order to successfully apply for QAP you need to satisfy the following criteria*: Mediated at least 6 disputes (either as a sole or a co-mediator) 2 of which must have been in the last 6 months 1 of which must have been remunerated (i.e. not pro-bono) *prior to achieving certification each candidate must sign a self-declaration stating you have completed 20 face-to-face mediations or 200 hours of mediation logged Please provide us with the following information: Total number of hours mediation experience in the last 5 years: Total number of cases mediated in the last 5 years: In the table below please provide a rough breakdown of your experience showing how many cases and hours in any given type of mediation and your role Type Hours Cases Role* Commercial Workplace Employment Family Separating Couples Community / Social Other *solo or co-mediator / internal / external Supporting evidence of evaluation and feedback: Please attach feedback / evaluation sheets from previous clients (feedback from at least three cases is required). It you require a formatted feedback form to have your clients record this information, please visit: cid=157&ctype=document

4 Mediation Education Please provide information relating to the mediation education you have successfully completed in the last 3 years: (60 hours of approved mediation education is required. If your mediation education provider is not from our pre-approved list we may contact you looking for information about the curriculum covered in your training and the type of certification achieved) Please provide information of current professional affiliations and information on any membership to mediation or ARD bodies: Are you a member of the nrm network Are you a member of the YMI Are you registered with the National Register of Mediators (Ireland) If you wish to forward copies of any certificates please feel free to do so. Please do NOT send originals as we cannot take any responsibility for them or return them to you.

5 Applicants Declaration Declaration & Checklist I declare that to the best of my knowledge the information I have provided in this application is correct and represents my mediation experience and education in a true light. Signed: Date: Applicants signature Checklist Please make sure all the information and supporting documentation is enclosed before submitting this application. Any missing information or documentation will cause a delay in the processing of your application. Item ü û Reason if item is missing All questions answered in full CV attached Feedback for 3 past cases Certificate / evidence of 60 hours mediation training This application has been signed Office Use Only Has the applicant shown evidence of enough mediation experience to meet the QAP entrée criteria? Has the applicant satisfied the criteria 0f 60 hours of mediation education? If Yes, was is it a pre-approved education Supplier? If not, has the applicant provided information about the training programme they successfully attended? Is the training an equivalent to The pre-approved programs? þ Application Approved Approved By: Company Stamp _ Date: