人民调解受理登记表_____年_____月_____日，人民调解委员会依当事人申请（人民调解委员会主动调解），经当事人同意，调解_________、_________之间的纠纷。

纠纷类型：____________________________________案件来源：（1）当事人申请（2）人民调解委员会主动调解纠纷简要情况：_____________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ _______________________________当事人（签名）____________________登记人（签名）___________________________________人民调解委员会_______年______月______日备注：此表由人民调解委员会填写人民调解调查记录时间：_______________________地点：_______________________参加人：_______________________被调查人：_______________________记录：________________________________________________________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________调查人（签名）_________________被调查人（签名）__________________记录人（签名）__________________人民调解记录时间：_______________________地点：_______________________当事人：_______________________参加人：_______________________人民调解委员会已将人民调解的相关规定告知各方当事人。

调解记录：________________________________________________________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ______________________________________________________________________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ 调解结果：1、调解成功；2、调解不成；3、有待继续调解当事人（签名盖章或按指印）__________________当事人（签名盖章或按指印）__________________人民调解员（签名）______________________记录人（签名）__________________________年_____月____日人民调解协议书当事人姓名__________性别________民族_______年龄________ 职业或职务______________________联系方式___________________ 单位或住址_________________________________________________ 当事人姓名__________性别________民族_______年龄________ 职业或职务______________________联系方式___________________ 单位或住址_________________________________________________ 纠纷主要事实、争议事项：________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ 经调解，自愿达成如下协议：_______________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ 履行协议的方式、时限：__________________________________ 本协议一式______份，当事人、人民调解委员会各持一份。

当事人（签名盖章或按指印）_______人民调解（签名）_____ 当事人（签名盖章或按指印）_______人民调解（签名）_____（人民调解委员会印章)______年_____月______日人民调解口头协议登记表当事人姓名__________性别________民族_______年龄________ 职业或职务______________________联系方式___________________ 单位或住址_________________________________________________ 当事人姓名__________性别________民族_______年龄________ 职业或职务______________________联系方式___________________ 单位或住址_________________________________________________ 纠纷主要事实、争议事项：________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ 经调解，自愿达成如下协议：_______________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ 履行协议的方式、时限：__________________________________ 当事人（签名）_________________________________ 人民调解（签名）__________________________________（人民调解委员会印章)______年_____月______日备注：此表由人民调解委员会填写人民调解回访记录当事人_______________________________________调解协议书编号_______________________________回访事由_____________________________________回访时间_____________________________________回访情况：__________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________回访人（签名）_______________________人民调解委员会______年_____月_____日卷宗情况说明___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________立卷人____________审核人____________立卷日期年月日人民调解委员会调解卷宗卷名：卷号：人民调解员：调解日期：立卷人：立卷日期：保管期限：备注：卷内目录人民调解申请书申请人姓名性别民族年龄职业或职务联系方式单位或住址被申请人姓名性别民族年龄职业或职务联系方式单位或住址纠纷简要情况当事人申请事项1、2、3、人民调解委员会已将申请人民调解的相关规定告知我，现自愿申请人民调解委员会进行调解。