Form R-22 Arbitrator's Questionnaire

FEDERAL MEDIATION AND CONCILIATION SERVICE
2100 K Street, NW
WASHINGTON, DC 20427

FMCS Form R-22
Revised January 2003

Form Approved
OMB No. 3076-0001
Expires 01-31-06

ARBITRATOR'S PERSONAL DATA QUESTIONNAIRE
I. BIOGRAPHICAL
E-Mail Address:

NAME: (Last, First, Middle)
Mr. ____ Ms. ____ Prof. ____ Dr. ____
CURRENT BUSINESS OR OCCUPATION:
BUSINESS ADDRESS 1:
Street:

BUSINESS ADDRESS 2: (or Home)
Street:

City, State, Zip:

City, State, Zip:

Phone:

(

)

Phone:

(

)

Fax:

(

)

Fax:

(

)

II. EDUCATION
INSTITUTION

MAJOR

DEGREE

YEAR

III. CERTIFICATIONS
PROFESSION

□
□

ISSUED BY

YEAR

ISSUED BY

YEAR

Attorney
Industrial Engineer

Others Relevant Certifications:
PROFESSION

IV. PROFESSIONAL MEMBERSHIPS:
Others Relevant Memberships:

□

National Academy of Arbitrators

□ American Arbitration Assn.

V. LABOR-MANAGEMENT RELATIONS EXPERIENCE (You MUST attach a resume that details your collective
bargaining experience.)
COMPANY/ORGANIZATION

POSITION

CITY/STATE

FROM (YR)

TO (YR)

PAPERWORK REDUCTION ACT NOTICE: The estimated burden associated with this collection of information is 30 minutes per respondent. Comments
concerning the accuracy of this burden estimate and suggestions for reducing this burden should be sent to the Director of Arbitration Services, Federal
Mediation and Conciliation Service (FMCS) 2100 K Street, N.W., Washington, DC 20427. Persons are not required to respond to this collection of information
unless it displays the currently valid OMB control number.

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VI. Does your current employment or professional activity involve representation, advocacy, or participation in
(If you answered Yes,
decision making for labor organizations or employers in any capacity? □ No □ Yes
you MUST attach a full explanation of these activities.)
VII. PRESENT FEDERAL, STATE, COUNTY OR LOCAL GOVERNMENTAL POSITIONS, IF ANY (full-time, parttime, elected or appointed)
VIII. PERMANENT PANELS ON WHICH YOU CURRENTLY SERVE (e.g., USPS/NALC)

IX. ARBITRATION ROSTERS ON WHICH YOU CURRENTLY SERVE (e.g., NMB)

X. As an arbitrator, please indicate your experience by ISSUE and check the appropriate box for the number of cases
for each issue identified.
ISSUE
ABSENTEEISM

1-4

5 OR MORE

ISSUE
OFFICIAL TIME

AFFIRMATIVE ACTION

PAST PRACTICES

ARBITRABILITY

PENSION AND WELFARE PLANS

BARGAINING UNIT WORK

PENSION CLAIM (FED. STATUTE)

CONDUCT (OFF-DUTY/ PERSONAL)

PROMOTION

DEMOTION

RETIREMENT

DISCIPLINE (NON-DISCHARGE)

SAFETY/HEALTH CONDITIONS

DISCIPLINE (DISCHARGE)

SENIORITY

DISCRIMINATION

SEXUAL HARASSMENT

•

AGE

•

DISABILITY

SUBCONTRACTING/CONTRACTING OUT

•

RACE

TENURE/REAPPOINTMENT

•

SEX

UNION SECURITY

•

RELIGION

•

NATIONAL ORIGIN

STRIKES, LOCKOUTS, WORK
STOPPAGES, SLOWDOWNS

WAGES
•

COST-OF-LIVING PAY

DRUG/ALCOHOL OFFENSES

•

HOLIDAY PAY

FRINGE BENEFITS

•

INCENTIVE PAY

•

BONUS

•

JOB CLASSIFICATION & RATES

•

HOLIDAYS

•

MERIT PAY

•

INSURANCE

•

OVERTIME PAY

•

LEAVE

•

SEVERANCE PAY

•

VACATION

•

VACATION PAY

GRIEVANCE MEDIATION

WORK HRS/SCHEDS/ASSGNMTS.

HEALTH/HOSPITALIZATION

WORKING CONDITIONS/WORK ORDERS

HIRING PRACTICES

VIOLENCE OR THREATS

JOB PERFORMANCE
JOB POSTING/BIDDING
JURISDICTIONAL DISPUTE
LAYOFFS/BUMPING/RECALL
MANAGEMENT RIGHTS

1-4

5 0R MORE

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XI. As an arbitrator, please indicate your experience by INDUSTRY and check the appropriate box for the number of
cases for each issue identified.
INDUSTRY
1-4 5 OR MORE
INDUSTRY
1-4
5 OR MORE
ADVERTISING

MACHINERY

AEROSPACE

MARITIME

AGRICULTURE

MEAT PACKING

AIRLINES

METAL FABRICATION

ALUMINUM

MINING

AUTOMOTIVE

NUCLEAR ENERGY

BAKERY

OFFICE WORKERS/CLERICAL

BANKING

ORGANIZATIONS

BEVERAGE

PACKAGING

BUILDING PRODUCTS

PAINT AND VARNISH

BREWERY

PETROLEUM/PETROCHEMICALS

BROADCASTING

PHARMACEUTICALS

CANNING

PLASTICS

CEMENT

PLUMBING

CHEMICALS

POLICE AND FIRE

CLOTHING

PRINTING AND PUBLISHING

COAL

PRISON GUARD

COMMUNICATIONS

PULP AND PAPER

CONSTRUCTION

RAILROADS

DAIRY

REAL ESTATE

DISTILLERY

REFRIGERATION/HVAC

EDUCATION

RESTAURANTS

ELECTRICAL EQUPMT./APPLIAN.

RETAIL STORES

ELECTRONICS

RUBBER/TIRE

ENTERTAINMENT/ARTS

SHIPBUILDING/DRY-DOCK

FEED & FERTILIZER

SPORTS

FOOD (MANU./PROC./SERVICE)

STEEL

FOUNDRY

STONE/QUARRY

FURNITURE

TEXTILE

GLASS/POTTERY

TOBACCO

GRAIN MILL

TRANSPORTATION

HEALTH CARE

TRUCKING AND STORAGE

HOTELS/MOTELS/CASINOS/
RESORTS

UPHOLSTERING

HOSPITALS/NURSING HOME

UTILITIES

IRON

WAREHOUSING

LUMBER

XII. As an arbitrator, please indicate your experience by SECTOR and check the appropriate box for the number of
cases for each sector identified.
SECTOR
1-4
5+
PUBLIC (NON-FEDERAL)
PUBLIC (FEDERAL)
PRIVATE

XIII. Registered with the Defense Finance and Accounting Service or Central Contractor Registration
XIV. LANGUAGE PROFICIENCY (Ability to conduct hearings):
Other (Specify):_________________

□ Spanish

□ French

□ Yes □ No
□ German

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XV. I AM EXPERIENCED IN THE FOLLOWING TYPES OF ARBITRATION CASES AND AM WILLING TO
ACCEPT SUCH CASES:
EXPEDITED

□Yes □No

EMPLOYMENT

□ Yes

No

□

INTEREST

□ Yes □No

FACTFINDER

□Yes □No

XVI. I have FEDERAL SECTOR EXPERIENCE and can be considered for international arbitration assignments.

□ Yes

□ No

XVII. FEES CHARGED:
Per Diem:

$__________

Cancellation:

$__________

Docketing:

$ _________

Please explain your fee schedule in detail.
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XVIII. Award Citations:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
XIX. Publications:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

XX. DATE AVAILABLE FOR APPOINTMENT (MM/DD/YY)

_________/_________/_________

XXI. CERTIFICATION OF ADVOCACY
I hereby certify that, if admitted to the Federal Mediation and Conciliation Service (FMCS) Roster of Arbitrators, I will immediately
notify FMCS should I undertake any activities deemed to constitute "advocacy" under FMCS Regulations, 29 C.F.R. 1404.5(c), and
withdraw from the Roster.

Signature:

________________________________________________ Date: __________________

I hereby affirm that the foregoing information is accurate, complete and true to the best of my knowledge. I understand that FMCS
has the right to verify any information contained herein. Any willful misrepresentation contained herein will constitute a basis for
rejection of this application by the FMCS Arbitrator Review Board. If approved by the Arbitrator Review Board, I affirm that I will
abide by FMCS Arbitration Policies and Procedures (29 C.F.R. 1404) and the Code of Professional Responsibility for Arbitrators of
Labor-Management Disputes. As a member of the FMCS Roster of Arbitrators, I affirm that any party that has selected me has the
right to verify any information listed on this application.

Signature:

__________________________________

Date: _______________________