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NYS-UCS ADR Court Roster Redesignation Request Form

Questions marked with a * are required
Please use this form to indicate that you have fulfilled the Continuing Education requirements of Part 146, read the Part 146 Continuing Education Guidelines, and would like to be redesignated to a roster with the court. The information requested below is necessary for the court to determine whether to redesignate you for the rosters you serve on. Please have the following information handy before completing this form: 
 
  • The Part 146 trainings you've taken. Please indicate which Part 146 trainings you've completed.
  • The Rosters you serve on. You can find this information by entering your name in the Statewide Mediator Directory
  • Information about the Continuing Education programs you've completed. Date, title, trainer, # of hours.

The brief form below will prompt you for the following information: 
 
1. Your Name and Contact Info
2. Your Professional Standing
3. Neutral Type and Training Status
Please indicate whether you are a mediator, a neutral evaluator, or both.
If you are an attorney, please indicate whether you are in good standing in the jurisdictions where you are admitted. 
Please indicate whether you have taken qualifying trainings under Part 146.4
4. The Rosters you serve on
By indicating where you serve on a roster, your affirmation will be automatically directed to the ADR Coordinator for each roster on which you serve. You only need to complete this form once. For mediators, if you are unsure of what rosters you're on, you may visit the Statewide Mediator Directory and search by your name. (Please use the Mediator Directory Update Form to update your record in the directory).
You will also be prompted to indicate the number of referrals you received and/or the number of cases you mediated during the reporting period.
5. The Continuing Education Programs you have attended during the reporting period
Please complete all fields for each program you attended, including the category field. These are the categories of programs that qualify as continuing education:
  1. ADR Skills and Practice: general content for an ADR practitioner. 
  2. ADR Ethics: content on ethics in ADR
  3. Case-Type Specific: relating to the subject matter of the types of cases you handle on an ADR roster.
  4. Intimate Partner Violence (IPV): specific content relating to identifying, screening for, and addressing intimate partner violence. 2 hours required for all Family and Matrimonial Mediators every two years. All Family and Matrimonial Mediators are required to take 4 hours of IPV Screening training to be eligible to serve on a roster -- this counts towards their CE requirement. 
    (starting the current 2023-24 reporting period)
  5. Antibias Training: programming that addresses neutral bias. 2 hours required for all Neutrals every two years. 
    (starting the current 2023-24 reporting period)
6. Your Affirmation and Signature
 
Please note that redesignation is not guaranteed for any particular roster.

Thank you. 
Name and Contact Information
1.Contact Information
Professional Standing
2.Are you an attorney?
3.
Since January 1, 2019, have you been in good standing with regards to any/all professional licensing/registration?
4.Please explain basis for not being in good standing.