Form 3320-0008App2008 U.S. Institute for Environmental Conflict Resolution Ros

U.S. Institute for Environmental Conflict Resolution
Application for the National Roster of
Environmental Dispute Resolution and Consensus Building Professionals

Disclosure & Instructions
DISCLOSURE OF ESTIMATED REPORTING BURDEN
Public reporting burden for this form is estimated to take an average of 150 minutes to complete. This
includes time for reviewing the instructions, searching existing data sources, gathering the data
requested, completing, reviewing, and updating the form.
GENERAL INSTRUCTIONS
Complete all information requested in the online application. DO NOT send a resume or other material in
lieu of or in addition to the online Application. Except where noted, information from these submissions
will be made available to authorized agencies through the Institute's web site. Incomplete applications
will be returned.
REPEAT STEPS
Sections marked by a * symbol in this preview document, are repeatable steps in the online application
(allowing you to add multiple items to those sections).
INSTRUCTIONS/GLOSSARY
Please review the Entry Criteria, the Instructions and the Glossary definitions completely. You
can view and print Instructions and Glossary as a whole from the right hand navigation bar on the online
application “Welcome..” page and from the top of any application page. Reading the Instructions and the
definitions in the Glossary before you submit is important.
At the end of the application process, you must agree to a set of terms and conditions by clicking the
"submit.." button, after which your application will be scored and submitted to the Institute for review.
Please Take Note That:
• In the Qualifying Case Experience section you need to list only enough 20-hour environmental
cases to add up to 200 hours (at least 2 cases and no more than 10 cases.) Including more in
the QCE section has no effect. Any remaining 20-hour environmental cases and your public
policy cases can/should be counted in the Additional Case Credit Question 1. (assuming you
were the principal professional on all these cases).
• A case includes the requirement that 20 case hours were spent on it and that it was within the
last 10 years. Case Hour is also defined.
• The definition of environmental dispute resolution and consensus building professional requires
that your role was as "any third party neutral engaged to assist all parties..." in various
collaborative processes.
• It does not include a role as a decision-maker, a representative/advocate, or a stakeholder.
• All your 20-hour complex environmental cases in the last ten years and your complex public
policy cases can be included in the answer to Additional Case Credit Question 2. (assuming,
again, you were the principal professional on all these cases).
• The Summary of Case Experience should reflect all the 20 hour environmental and public policy
cases in which you were the principal professional in the last 10 years.
• The Detailed Case Information allows you to choose up to five environmental cases to highlight.
It is helpful to include details of cases listed in the Qualifying Case Experience here. Do not
include cases in which you were a decision-maker, representative/advocate, or a stakeholder.

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Saving Information in on-line application: As you progress through your application, your information
will be saved. Remember to click "Save and Continue" at the bottom of the page, where available. When
making changes use the application's edit/delete function where available and click "update" button at
the bottom of the edit/delete window) or use the delete/backspace function on your keyboard and click
"save and continue" at the bottom of the page. If the changes you have made do not appear, try clicking
"Refresh" on your browser's toolbar or closing the application and re-opening it. The changes should
appear.
To select more than one item in a dropdown box, hold down the "control" key on a PC or "command" key
on a MAC while making selections. To change a selection, hold down the control or command key while
clicking on an item you have selected; this should clear the item selected.

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General Information

Asterisked fields must be completed before proceeding to the next section of the application.
*Last Name: _______________________________
* First Name: _______________________________
Middle Initial: _______________________________
* Address: _______________________________
_______________________________
* City: _______________________________
* State: _______________________________
* Zip _______________________________

Fax: _________________________

* Telephone: _______________________________

* E-mail: _________________________
Organization, if _______________________________
URL: _________________________
any:
Position/Title: _______________________________ Are you are a Federal Employee?
(Yes or No)
Non-profit
Government Agency
ADR Firm
Law Firm
Other Business:

Services Provided

A. Environmental Dispute Resolution and Consensus Building Services.
Check each service that you have experience in providing and are willing to provide
in the future:
Mediation
Facilitation
Regulatory Negotiations
Consensus Building/Policy Dialogues
Superfund Allocation
Neutral Evaluations/Fact Finding
Conflict Assessment/Process Design
Dispute Systems Design
B. Areas where you have previously worked:
New England: CT, MA, ME, NH, RI, VT
Mid-Atlantic: DE, MD, NY, NJ, PA, VA, WV, Washington D.C.
Southeast: AL, FL, GA, KY, MS, NC, SC, TN
Great Lakes: IL, IN, MI, MN, OH, WI
North Central States: IA, KS, MO, ND, NE, SD
South Central States: AR, LA, OK, TX
Mountain: CO, ID, MT, WY
Southwest: AZ, NM, NV, UT
California
Pacific Northwest: AK, OR, WA
Pacific Islands: HI, Guam, and Amer. Samoa
Atlantic Islands: PR, VI
Foreign Countries (List below):
_____________________________________________________________

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C. Capacities to handle special requirements (either internal to your organization,
or through subcontracting).
Experience with complex scientific/technical issues
Logistical support for complex cases
Meeting summaries and reports
Translation and Interpretation
Languages:
Information management
Computer support (e.g., list serve, web page)
Access to technical experts
Access to other ADR providers
Evaluation of ADR processes
Dispute resolution training
Negotiation training
Other:
D. Fee Structure
Hourly Rate: ______________________________________________________________
__________________________________________________________________________
Hourly Rate Includes: ______________________________________________________
__________________________________________________________________________
Pro-bono or Reduced rates:

(Yes or No)

Hourly Rate does not include:________________________________________________
__________________________________________________________________________
Comments:

Qualifying Cases*

Environmental Dispute Resolution and Consensus Building Case Descriptions:
In this section you will be asked to enter a minimum of two but a maximum of ten 20hour environmental cases that in aggregate total 200 case hours. List only those cases
in which you were the principal or a co-principal. List only those cases that have been
completed in the last 10 (ten) years. See terms defined in the Glossary.
Descriptive Case Name:

_______________________

Primary ADR Role:
If no ADR role listed in drop
down menu (in the online
application) matches
appropriately, please
specify another
Estimated number of case
hours:

_______________________

_______________________

Case end date or expected
finish date if ongoing (in
_______________________
MM/YYYY format):

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References

For two of the cases listed in Qualifying Case Experience, provide two references for each case.
Please provide reference addresses and phone numbers.

NOTE: The reference information is for Institute use only and will not be available to other parties.

Case 1:
Name: _______________________
Telephone: _______________________
Address: ______________________________________________
Name: _______________________
Telephone: _______________________
Address: ______________________________________________
Case 2:
Name: _______________________
Telephone: _______________________
Address: ______________________________________________
Name: _______________________
Telephone: _______________________
Address: ______________________________________________

Additional Case Credit

Credit for work in addition to that listed in Qualifying Cases. See terms defined in the Glossary.

1. Number of environmental or public policy cases in which you served as a principal in the last
10 years. (do not count here cases used to meet the 200 case hour "Qualifying Cases" criterion)
(1, 2, 3, 4, 5 or more)
2. Total number of complex environmental or public policy cases in which you served as a
principal in the last 10 years. (see definition of complex in glossary)
(1, 2, 3, 4, 5 or more)
3. Credit for environmental or public policy cases in which you served as an apprentice or junior
professional in the last 10 years.
(1, 2, 3, 4, 5 or more)

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Detailed Case Information*

Provide the following descriptive information for up to 5 environmental cases that represent the
nature and scope of your work.
Descriptive Case Name: _______________________________________________
(Cases which you’ve added in “Qualifying Cases” will appear here, allowing you to add detailed
information which will automatically correspond with previously entered Case information)
OR, if this Case isn't already listed and named in your profile, (reflected in the drop down menu
above), please enter Descriptive Case Name below (up to 50 characters):
_______________________________________________________________________
Case Type:
Agricultural issues
Air Quality
Allocation of Liability for
Damages
Archeological, Historic Case
Preservation,
Brownfields
Coastal Zone Issues
Cross-cultural Issues
Ecosystem Management,
Endangered Species
Energy Issues
(Conservation, Hydro,
Nuclear, Oil & Gas)
Environmental Enforcement
and Permitting
Environmental Justice
Facility Siting
Fisheries
Floodplain
Forestry

Hazardous Waste
Insurance Coverage
Land Use, Growth
Radioactivity (Waste,
Substances, Storage,
Leakage, Transport)
Recycling
Conservation
Resource Management
Management, & Sustainable
Development
Landfills
Military/Base Issues
Mining
Native American Issues
NEPA
Oceans
Oil and Gas Production
Pesticides, Toxic Substances
Public Health
Public Lands Issues

Right-to-Know, Consumer
Safety
Solid Waste Issues
Superfund
Transportation: Highways
Transportation: Mass Transit
Transportation: Bridges
Transportation: Airports
Transportation: Others
Treaties
Urban Infrastructure (Utilities,
Communication, Facilities,
Sewerage, etc.)
Water
Management/Allocation/Rights
Water Quality/River Basins
Watershed
Management/Planning
Wetlands/Estuaries
Wildlife Issues
Other

Case Narrative:
(Describe your role, types of parties, issues and outcomes of each case.)

Training Hours

Please answer the following: (see terms in Glossary)
Have you taken 24 hours of basic training and an additional 16 hours of advanced training in
mediation, facilitation, or consensus building?

(Yes or No)

Have you provided at least 40 contact hours of training in mediation, facilitation, or consensus building?
(Yes or No)

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Have you provided at least 150 contact hours of training in mediation, facilitation, or consensus building?
(Yes or No)

Training Courses*
Course Name: _______________________
Course Length: _______________________
Year: _______________________
Course Sponsor/Provider: _______________________
Your involvement: _______________________

Relevant Education*
Graduate Education and Program Certifications:
Name of School: _______________________
City and State of School: _______________________
Degree or Certification achieved: _______________________
Focus of Degree: _______________________
Year of Degree: ___________

Relevant Work & Volunteer Experience*
Organization: _______________________
Full time or Part Time: _______________________
Occupation, Position or Title: _______________________
Start Date (mm/yyyy): _______________________
End Date (mm/yyyy): _______________________

Language Skills *

Language: _____________________________
Fluency: (Fair, Good, Excellent)

Summary & Narrative of Experience

Summary of Case Experience:

Total number of public policy and environmental cases in the last 10 years:
Average number of hours per case:

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Narrative Description of Experience: (Optional)
Summarize your experience in mediation, facilitation, and other dispute resolution services in the space
below. Provide information that you believe would be useful to parties including your professional strengths
and style of practice.

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Ethnicity & Gender (Optional)
Ethnicity:

Gender:

American Indian/Alaskan Native
African American
Asian
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White (not of Hispanic origin)
(Male or Female)

Minority Affiliation:
Are you affiliated with an organization that is 51% or more owned by one or more minority groups?
(Yes or No)

Areas of Substantive Knowledge

Educational & Professional Experience:
In the left column below, mark all of the categories in which you have either received a degree or
certificate, or have significant professional work experience.
Architecture, Historic Preservation
Cultural Studies
Building Trades Construction, Development, Real Estate
Communications, Public Relations
Conflict Resolution
Economics, Finance
Education
Engineering
Health: e.g., Medicine, Public Health
International Relations
Law
Life Sciences (i.e.: Biology, Ecology)
Organizational Development/Strategic Planning
Planning, Urban Studies
Public Interest Work
Public Policy, Political Science, Government
Physical Sciences: e.g., Chemistry, Physics, Geology
Social Science: e.g., Sociology, Psychology, Mental Health
Social Services
Other:

Areas of Substantive Knowledge

Case Types:
In the left-hand column below, mark all of the case categories in which you have served as an ADR
provider.
Agricultural issues
Air Quality
Allocation of Liability for Damages
Archeological, Historic Preservation
Brownfields
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Coastal Zone Issues
Cross-cultural Issues
Ecosystem Management
Endangered Species
Energy Issues (Conservation, Hydro, Nuclear, Oil & Gas)
Environmental Enforcement and Permitting
Environmental Justice
Facility Siting
Fisheries
Floodplain
Hazardous Waste
Land Use, Growth Management, Sustainable Development
Landfills
Military/Base Issues
Mining
Native American Issues
NEPA
Oceans
Oil and Gas Production
Pesticides, Toxic Substances
Public Health
Public Lands Issues
Radioactivity (Waste, Substances, Storage, Leakage, Transport)
Recycling, Conservation
Resource Management
Right-to-Know, Consumer Safety
Solid Waste Issues
Superfund
Transportation: Highways
Transportation: Mass Transit
Transportation: Bridges
Transportation: Other
Treaties
Urban Infrastructure
Water Management/Allocation/Rights
Water Quality/River Basins
Watershed Management/Planning
Wetlands/Estuaries
Wildlife Issues
Other:

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Conditions for Listing

Applicants who qualify for inclusion on the Roster and wish to be listed must agree to the
following terms:
a. To abide by the Model Standards of Conduct for Mediators approved by the Society of
Professionals in Dispute Resolution, the American Bar Association, and the American Arbitration
Association.
b. To abide, where applicable, by the U.S. Institute for Environmental Conflict Resolution's
Confidentiality Policy.
c. To be subject to removal from the roster for good cause such as:
i.

Submission of materially false application data;

ii.

Failure to provide non-confidential information required by the Institute for
management and evaluation of the roster;

iii.

Failure to disclose to prospective parties any conflicts of interest or other
circumstances likely to create actual or perceived bias;

iv.

Engaging in unethical or illegal behavior pursuant to a case handled through the
roster referral process;

v.

Improper disclosure of confidential information related to a case handled
through the roster referral process;

vi.

Deviation from the Model Standards of Conduct for Mediators.

Certification
I certify that all information submitted by me on this application is correct to the best of my
knowledge. I wish to be listed on the roster if found to meet the qualifications for inclusion.
Moreover, I have read, understand and agree to abide by all terms set forth in the Conditions for
Listing Agreement (above), of this application as a condition for listing on the roster. I further
understand that false certification may subject me to civil or criminal penalties as
prescribed in 18 U.S.C. 1001. I also understand that all information provided by me on this
application is public record.
In my application, I certify that I am not currently debarred, suspended, proposed for debarment or
suspension, nor have I been declared ineligible for the award of contracts by any Federal agency.
You be asked to click the submit button as certification.

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