Mediator Roleplay Evaluation Form
Evaluate mediator roleplay performance, rate core competencies, and provide structured feedback in this form.
Scenario and Participant Details
Evaluator Name
*
Roleplay Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Mediation Scenario / Topic
*
Participant or Trainee Being Evaluated
*
Session Length (minutes)
*
Evaluation Scores
Mediator Competencies
*
Rows
Poor
Below Average
Average
Good
Excellent
Active listening
1
2
3
4
5
Neutrality / impartiality
6
7
8
9
10
Communication clarity
11
12
13
14
15
Conflict de-escalation
16
17
18
19
20
Issue reframing
21
22
23
24
25
Session control
26
27
28
29
30
Overall Performance Rating
*
1
2
3
4
5
Evaluator Feedback
Strengths Observed
Areas for Improvement
Final Recommendation
*
Pass
Needs Improvement
Retake Recommended
Submit Form
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