一、基本信息項目內(nèi)容:---------------:-------------------------------------------------------------------**糾紛編號**(由受理單位按規(guī)則統(tǒng)一編制)**排查/受理日期**年月日時分**糾紛類別**□鄰里糾紛□婚姻家庭糾紛□合同糾紛□勞動爭議□物業(yè)糾紛□損害賠償糾紛□其他（請注明：______）**發(fā)生地點****涉及人數(shù)**共人(其中：主要當(dāng)事人人，相關(guān)方人)**記錄單位****記錄人****聯(lián)系方式**二、當(dāng)事人基本情況當(dāng)事人角色(申請人/被申請人/其他)姓名性別出生年月民族文化程度職業(yè)/身份住址/單位聯(lián)系電話:---------------------------:-------:---:---------:---:-------:----------:----------------------------:-------------三、糾紛排查與受理情況（一）排查發(fā)現(xiàn)/受理來源（請詳細(xì)描述糾紛是如何被排查發(fā)現(xiàn)的，如：日常走訪、群眾反映、上級交辦、其他單位移送等，并簡述初步情況。）________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________（二）糾紛簡要情況及主要事實（請客觀、準(zhǔn)確地簡述糾紛發(fā)生的時間、地點、起因、經(jīng)過、當(dāng)前狀況以及各方爭議的核心問題。力求簡明扼要，突出關(guān)鍵事實。）________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________（三）當(dāng)事人訴求摘要1.（申請人/主要一方當(dāng)事人訴求）：________________________________________________________________________________________________________________________________________________2.（被申請人/另一方當(dāng)事人訴求）：________________________________________________________________________________________________________________________________________________3.（其他相關(guān)方訴求，如涉及）：________________________________________________________________________________________________________________________________________________四、調(diào)解過程與主要內(nèi)容（一）調(diào)解時間與地點首次調(diào)解時間：______年______月______日______時______分地點：____________________再次調(diào)解時間（如多次）：______年______月______日______時______分地點：____________________（可根據(jù)實際調(diào)解次數(shù)增減）（二）調(diào)解員信息（如與記錄人不同或有多名調(diào)解員）主調(diào)解員：____________單位/職務(wù)：____________________聯(lián)系方式：____________________協(xié)助調(diào)解員：____________單位/職務(wù)：____________________聯(lián)系方式：____________________（三）調(diào)解方式□單獨溝通□雙方到場調(diào)解□多方參與調(diào)解□其他（請注明：________________）（四）調(diào)解過程記錄（詳細(xì)記錄調(diào)解的具體步驟、方法、調(diào)解員所做的工作、當(dāng)事人在調(diào)解過程中的陳述、情緒變化、對事實和責(zé)任的認(rèn)可程度、提出的解決方案及協(xié)商情況等。應(yīng)體現(xiàn)調(diào)解的動態(tài)過程和關(guān)鍵節(jié)點。）________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________（如調(diào)解過程較長或分多次進行，可分段記錄）________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________（五）法律法規(guī)及政策依據(jù)（記錄調(diào)解過程中引用的主要法律法規(guī)、政策規(guī)定、村規(guī)民約、公序良俗等，體現(xiàn)調(diào)解的合法性與合理性。）________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________五、調(diào)解結(jié)果（一）調(diào)解達成協(xié)議1.協(xié)議主要內(nèi)容：（清晰、具體、可操作地列明雙方當(dāng)事人達成的一致意見，包括權(quán)利義務(wù)、履行方式、履行期限、違約責(zé)任等。如有多項，可分條列明。）(1)________________________________________________________________________________________________________________________________________________(2)________________________________________________________________________________________________________________________________________________(3)________________________________________________________________________________________________________________________________________________(4)本協(xié)議一式______份，當(dāng)事人各執(zhí)______份，調(diào)解單位存檔______份，具有同等效力。2.履行情況：□當(dāng)場履行完畢□分期履行，首期已于______年______月______日履行□約定于______年______月______日前履行完畢□其他：____________________（二）調(diào)解未達成協(xié)議1.未達成協(xié)議原因：（簡述未能達成協(xié)議的主要原因，如：分歧過大、一方態(tài)度強硬、當(dāng)事人需進一步考慮等。）________________________________________________________________________________________________________________________________________________2.后續(xù)處理建議/途徑：（根據(jù)實際情況，向當(dāng)事人告知其可選擇的其他解決途徑，如：行政復(fù)議、行政裁決、仲裁、訴訟等，并記錄當(dāng)事人的意愿或下一步打算。）________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________（三）其他情況（如：當(dāng)事人撤回申請、糾紛不屬于本單位調(diào)解范圍已移送等，請具體說明。）________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________六、附件材料清單（如有相關(guān)證據(jù)材料、照片、錄音錄像資料（注明存放處）、當(dāng)事人身份證明復(fù)印件等，請在此列明。）1.______________________________________2.______________________________________3.______________________________________七、當(dāng)事人簽名及日期當(dāng)事人簽名:---------:-------:-------:-------(申請人)(被申請人)(其他方)日期年月日年月日年月日八、調(diào)解員簽名及調(diào)解單位蓋章調(diào)解員簽名:---------:-------------:-------------(主調(diào)解員)(協(xié)助調(diào)解員)日期年月日年月日調(diào)解單位(蓋章)日期年月日九、備注（其他需要說明的事項，如：是否申請司法確認(rèn)、履行情況跟蹤記錄等。）______________________________________________________________________________________________________________________________________________________________