Form R-22 Arbitrator's Personal Data Questionnaire

FEDERAL MEDIATION AND CONCILIATION SERVICE
ARBITRATOR'S PERSONAL DATA QUESTIONNAIRE

FMCS Form R-22
Revised February 2022
(202) 606-5111

Form Approved
OMB No. 3076-0001
Expires XX-XX-XXXX

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)

Privacy Act Statement. 29 U.S.C. § 172, et seq., authorize the FMCS to collect this information. The primary use of the information is to allow FMCS officials to
maintain a roster of arbitrators. Additional disclosures of the information may be made: (1) to a Federal, State, or local law enforcement agency if FMCS becomes aware
of a violation or potential violation of law or regulation; (2) to a court or party in a court or Federal administrative proceeding if the Government is a party or in
order to comply with a judge-issued subpoena; (3) to the National Archives and Records Administration or the General Services Administration in record management
inspections; (4) to the Office of Management and Budget during legislative coordination on private relief legislation; (5) in a judicial or administrative proceeding if the
information is relevant to the subject matter; (6) to provide arbitrator information to parties seeking arbitration services; and (7) information collected may be used by
FMCS to provide information concerning FMCS trainings, events, presentations, conferences, and other educational opportunities and programs. This information is
voluntary and will not be disclosed unless authorized by law. Failure to provide the requested information could result in not being included on FMCS’s arbitration
roster.

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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. Please indicate your experience as a labor relations professional, advocate, or neutral 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

STRIKES, LOCKOUTS, WORK
STOPPAGES, SLOWDOWNS

•

DISABILITY

SUBCONTRACTING/CONTRACTING OUT

•

RACE

TENURE/REAPPOINTMENT

•

SEX

UNION SECURITY

•

RELIGION

•

NATIONAL ORIGIN

•

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

WAGES

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. Please indicate your experience as a labor relations professional, advocate, or neutral by INDUSTRY and check
the appropriate box for the number of cases for each industry 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. Please indicate your experience as a labor relations professional, advocate, or neutral 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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_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
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_________________________________________________________________________________________________________
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_________________________________________________________________________________________________________
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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: _______________________

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FEDERAL MEDIATION AND CONCILIATION SERVICE
OFFICE OF ARBITRATION SERVICES
GEOGRAPHICAL LOCATIONS FOR ARBITRATORS

New York, NY
Long Island, NY
Albany, NY
Syracuse, NY
Buffalo, NY
Newark, NJ
Boston, MA
Worcester, MA
Hartford, CT
Providence, RI
Concord, NH
Portland, ME
Philadelphia, PA
Pittsburgh, PA
Erie, PA
Parkersburg, WV
Harrisburg, PA
Allentown, PA
Trenton, NJ
Baltimore, MD
Washington, DC
Richmond, VA
Atlanta, GA
Birmingham, AL
Mobile, AL
New Orleans, LA
Memphis, TN
Nashville, TN
Chattanooga, TN
Knoxville, TN
Charlotte, NC
Jacksonville, FL
Tampa, FL
Miami, FL
Cleveland, OH
Akron, OH
Toledo, OH
Columbus, OH
Dayton, OH
Cincinnati, OH
Louisville, KY
Detroit, MI
Saginaw, MI

1

101
102
103
104
105
106
107
108
109
110
111
112
213
214
215
216
217
219
220
221
222
223
326
327
328
329
330
331
332
333
334
335
336
337
441
442
443
444
445
446
447
448
449

Grand Rapids, MI
Kalamazoo, MI
Chicago, IL
Peoria, IL
Rockford, IL
South Bend, IN
Indianapolis, IN
Evansville, IN
Milwaukee, WI
Green Bay, WI
Minneapolis, MN
St. Louis, MO
Cedar Rapids, IA
Des Moines, IA
Omaha, NE
Kansas City, MO
Wichita, KS
Oklahoma City, OK
Springfield, MO
Little Rock, AR
Dallas, TX
Houston, TX
San Francisco, CA
Los Angeles, CA
San Diego, CA
Seattle, WA
Portland, OR
Spokane, WA
Great Falls, MT
Salt Lake City, UT
Denver, CO
Phoenix, AZ
Albuquerque, NM
Honolulu, HI
Sacramento, CA
Anchorage, AK
Cheyenne, WY
Lewiston, ID
Fargo, ND
Rapid City, SD
Las Vegas, NV
Jackson, MS
South Carolina

450
451
554
555
556
557
558
559
560
561
562
665
666
667
668
669
670
671
672
673
674
675
778
779
780
782
783
784
785
786
787
788
789
790
791
792
793
794
795
796
797
798
799

1

Virgin Islands
Toronto, Canada
Columbia, MO
Southern Illinois
Rochester, NY
Delaware
Vermont
Buffalo, NY
Kansas City, KS
Montreal, Canada
Reno, NV
Puerto Rico

801
813
815
816
817
819
821
806
822
823
824
835

Please circle only one city if you use one business address or two cities if you use two business addresses that is nearest the
address(es) you intend to establish your arbitration practice. For example, if your practice is located in The Woodlands, Texas,
you would circle Houston, TX only.