Mediation form submission

Alternative Dispute Resolution (ADR) unit – mediation request form

This online mediation request form is used to request a mediation session with an ADR mediator at the Department of Labor and Industry (DLI). The form gathers necessary information and allows users to select a preferred mediator and preferred mediation date and time. The submission will be sent to an ADR mediation scheduler for completion of the scheduling process.

A mediation request may also be made by contacting ADR at (651) 284-5005, 1-800-342-5354 or

To complete the mediation request form, the user will need the following information:
  • WID number or Social Security number;
  • date of injury;
  • employee name;
  • need for an interpreter;
  • name of requesting party;
  • names of opposing counsel;
  • desired location; and
  • preferred mediator, dates and times.

Selecting the mediator
The system provides a drop-down box listing all ADR mediators. Clicking on the mediator’s name will display the mediator’s already scheduled appointments; users should select a date when the mediator does not already have an appointment scheduled.

Selecting the preferred date
The system provides a box where the user may select their preferred mediation date and a box for a second preferred mediation date.

Additional information
The system provides a box where the user can provide additional information or special requests.

Submitting the form
After completing the form, the user should click “Submit.” A message will appear confirming the request was successfully sent and the form will be sent to ADR.