Appellate Screening Form PDF Details

This screening questionnaire is a key procedural document in California's appellate system. The Fifth Appellate District uses it to evaluate whether a civil appeal is a good fit for its mediation program. Below is a breakdown of what the form covers and what you need to know before completing it.

Who Must File This Form

Every party involved in a civil appeal before the Fifth Appellate District must complete this questionnaire. That includes both appellants and respondents. If you are represented by an attorney, your lawyer submits the form on your behalf. Unrepresented parties file it directly with the clerk.

The court typically sends a notice after the appeal is docketed. You must respond within the deadline stated in the notice. Failing to file on time may affect your case's eligibility for the mediation program.

What the Form Asks For

The questionnaire gathers factual details about your case so a justice can assess its suitability for mediation. You will be asked to provide:

Answer each question completely. A sitting justice reviews your responses alongside those of the opposing party to decide whether to recommend the case for mediation.

When Mediation May Be Ordered

If the court selects your case, a trained mediator works with both sides before significant resources are spent on appeal records and briefs. Mediation under this program is conducted by a sitting justice or a qualified neutral. Settlements reached at this stage are binding.

Not every case qualifies. Factors that typically weigh against selection include cases with no realistic settlement value, highly adversarial relationships, or legal questions that require a court ruling to resolve. The form's detailed questions help the court sort cases quickly.

For related legal documents, you may also need an appeal form to initiate the appellate process, or a mediation statement form if your case proceeds to a structured mediation session. Parties in California civil actions may also need to file a California civil form for related case management purposes.

QuestionAnswer
Form NameAppellate Screening Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesappellate district determine make, ca court of appeal 5th district, fifth appellate district california court of appeal, fifth appellate district

Form Preview Example

COURT OF APPEAL, FIFTH APPELLATE DISTRICT

CIVIL APPEAL CASE SCREENING QUESTIONNAIRE

TO DETERMINE SUITABILITY FOR MEDIATION

This questionnaire will assist the court in selecting cases for mediation to be conducted by a sitting justice of this court. The court intends to select cases shortly after the notice of appeal is filed and before the expense of preparing the record on appeal and appellate briefs has been incurred, This questionnaire is to be completed and signed by each party, or their counsel of record, and served on all other parties, or counsel of record, and filed with the court within ten (10) calendar days of mailing of this questionnaire.

1.Case Name and Number: ____________________________________________________

2.Name of Party/Client:

3.Name of Attorney:

4.Subject Matter (Check all that apply):

☐ Attorney Fees

☐ Family Law

☐ Personal Injury

☐ Business/Contract

☐ Insurance

☐ Probate

☐ Construction

☐ Professional Negligence

☐ Intellectual Property

☐ Employment

☐ Environmental

☐ Real Estate

☐ Other (specify):

5.Date Notice of Appeal Filed:

6.Trial Court Venue:

7.Name of Trial Judge:

8.The trial court judgment resulted from:

☐ Jury Trial

☐ Court Trial

☐ Summary Judgment

☐ Demurrer

☐ Dismissal

☐ Nonsuit

☐ Arbitration Award

☐ Administrative Mandamus

☐Order (specify):

☐Other (specify):

9.What was the judgment?:

10.Length of trial or hearing appealed from: _____ (number of court days)

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You have a maximum of 1000 words to address questions 11-19 on this page. Please use the text box immediately following question 19 to respond and please identify which question you are addressing (i.e., #2., #3. etcetera.)

11.If there have been any prior appeals in this case (or a related case), state the case name, case number and identify the appellate court:

12.Has anything changed since the most recent settlement offers/demands that may affect the settlement position of any party?: ( If so, explain. )

13.Identify all ADR processes in this case in which you have participated (e.g., mediation, arbitration, or settlement conferences). State the name of all judges, mediators, or other neutral parties involved and the dates of same:

14.Briefly state the facts of the case:

15.Describe any ongoing personal, professional, or business relationship between any of the parties to this appeal:

16.Identify all persons, other than the parties, whose agreement is necessary for the mediation of this appeal and any related litigation or dispute (e.g., an insurance adjuster, spouse, lien holder):

17.State whether any boards, councils or groups of persons must approve any settlement agreement:

18.Identify the primary issues on appeal:

19.Is there a claim for recovery of attorney fees?: (If so, state the amount and legal authority.)

2

20.Are there any insurance issues that may hinder settlement?:

21.Are there any liens?: (If so, state their amounts.)

22.State whether you believe this case would benefit from a mediation conducted by the appellate court.:

☐Yes ☐No

23. If you indicated “No,” explain your reasons:

24. The impediments, if any, to resolving this case are:

Date:

Signature

Print Name of Party or Attorney

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How to Edit Appellate Screening Form Online for Free

You can complete this document online without downloading any software. Our PDF editor lets you fill in text fields, add signatures, and save your work at any stage. Follow the steps below to finish the form quickly and accurately.

Step 1: Open the form in the editor

Click the "Get Form" button at the top of this page. The editor loads the document in your browser. No installation is needed.

Step 2: Complete the party information

Enter the case number, court name, and the names of all parties exactly as they appear in the trial court records. Errors here can cause the clerk to reject your submission. Double-check spelling against your original court paperwork.

Filling in party names and case number on the appellate screening form

Step 3: Describe the judgment and trial proceedings

Indicate how the trial court judgment was reached. Options include jury trial, court trial, summary judgment, arbitration, demurrer, or administrative mandamus. Also record the approximate length of the original trial or hearing. These details help the court assess the scope of the dispute.

Completing the trial court judgment section of the appellate screening form

Step 4: Disclose prior appeals and ADR history

State whether any prior appeals have been filed in this case. Describe any alternative dispute resolution processes that have already taken place, including private mediation or arbitration. If settlement talks occurred, note their outcome without disclosing privileged communications.

Prior appeals and ADR history section of the appellate screening form

Step 5: Address insurance and lien issues

Identify any insurance carriers that have a coverage interest in the case. List any liens, including attorney liens, that could affect how settlement proceeds would be distributed. Incomplete disclosure here can delay or derail a mediation agreement.

Insurance and lien disclosure fields in the appellate screening form

Step 6: State your mediation suitability assessment

Indicate whether you believe the case is suitable for mediation. If you answer No, provide a brief explanation. Be candid. A sitting justice weighs both parties' assessments when deciding whether to refer the case.

Step 7: Sign and submit

Enter the date, your signature, and your printed name in the fields at the bottom of the form. Each party or their counsel must sign separately. After all fields are complete, click "Done" to save a copy to your FormsPal account. You can then download, print, or share the finished document.

Signature, date, and printed name fields at the bottom of the appellate screening form

For other court-related documents, explore our collection of judicial branch forms and appeal request forms available on FormsPal.

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