JUROR INFORMATION QUESTIONNAIRE

1. Your Full Name: ___________________________________________________________________________________
2. Present Address: ____________________________________________________________________________________
3. Telephone Number: Home ( ) ____-______ Office ( ) ____-______ Miles (approx.) from Courthouse: _______
4. Place of Birth: _____________________________________________________________________________________
5. Parents' Birthplaces--Father: __________________________________________________________________________
Mother: ________________________________________________________________________
6. Date of Birth: ___-___-_____ and Race: ______________
7. Have you lived at any other address during the last ten years? YES: ___ NO: ___ If YES, what address[es]:
(a) ___________________________________________________________; Dates: _____________________________
(b) ___________________________________________________________; Dates: _____________________________
(c) ___________________________________________________________; Dates: _____________________________
8. Please state the Schools which you have attended:
(a) Grade School: _____________________________________________; Dates: _______________________________
(b) Junior High: ______________________________________________; Dates: _______________________________
(c) High School: ______________________________________________; Dates: _______________________________
(d) College: __________________________________________________; Dates: _______________________________
(e) Vocational or Trade School: _______________________________; Dates: _______________________________
(f) Professional School: ______________________________________; Dates: ________________________________
(g) Graduate School: __________________________________________; Dates: _______________________________
(h) Degrees or Diplomas which you hold: _______________________________________________________________
9. What work do you do: _______________________________________________________________________________
10. Who is your employer: _______________________________________________________________________________
11. What is your position, and what are your duties in that position: ___________________________________
_________________________________________________________________________________________________________
12. How long have you been with the same employer: _______________________________________________________
13. For whom else have you worked in the past ten years:
(a) ___________________________________________________________; Dates: ______________________________
(b) ___________________________________________________________; Dates: ______________________________
(c) ___________________________________________________________; Dates: ______________________________
14. Have you ever been in the military service: _______________ Branch: _____________________________________
Dates/Duties: ______________________________________________________________________________________
15. Have you ever worked as a volunteer or employee in a law enforcement agency, prison, jail, correctional institution or mental health facility on the local, state or federal level: _______________________________________
When and where: __________________________________________________________________________________
16. Has a member of your family ever worked as a volunteer or employee in a law enforcement agency, prison, jail, correctional institution or mental health facility on the local, state or federal level: ___________________________
Who, and what relationship: ________________________________________________________________________
When and where: __________________________________________________________________________________
17. Have you ever appeared as a witness before a Grand Jury or a Justice of the Peace: ________________________
When and where: __________________________________________________________________________________
18. Have you ever been a witness in a criminal prosecution: ____ On behalf of the State ____ or the Defendant ____
When and where: __________________________________________________________________________________
19. Have you ever appeared as a witness in a civil case _______ For the Plaintiff ________ or the Defendant ______
20. Have you ever served on a Jury before: __________ Was this a Grand ________ or a Petit (trial) _________ Jury?
If a civil case: ___ Did the Jury reach a verdict: ___ If not, please explain: ________________________________
____________________________________________________________________________________________________
If a criminal case: ___ What was the charge:____________________________________________________________
Did the Jury reach a verdict: _____ If not, please explain: _________________________________________________
21. Have you ever been a party to a Civil Action: __________ Were you the Plaintiff _____ or the Defendant ______
Was the verdict in your favor: __________________ Please Explain: ________________________________________
22. Have you ___ or any member of your family ___ or any close friend ____ ever been the victim of a violent crime? What was the crime: ________________________________________________________________________________
Was anyone arrested ____ and/or convicted ____ in connection with that crime: ______________________________
23. Have you ___ or any member of your family ___ or any close friend ____ ever been arrested for a crime?
What were the crime(s): _____________________________________________________________________________
24. Have you ___ or any member of your family ___ or any close friend ____ ever been convicted for a crime?
What were the crime(s): _____________________________________________________________________________
25. What is your:
Political Party Preference: ____________________________________________________________________________
Religious Affiliation: _________________________________________________________________________________
26. Please list the organizations to which you belong (Social, Fraternal, Service, Charitable, etc.): _________________
_____________________________________________________________________________________________________
27. Please list your Hobbies (Spare time activities): __________________________________________________________
_____________________________________________________________________________________________________
28. What Newspapers do you read (please state how many times per week with each one): _______________________
_____________________________________________________________________________________________________
29. Please list the magazines and periodicals which you most often read: 1. _____________________________________
2. _____________________________________________ 3. ___________________________________________________
30. What are your favorite T.V. programs: 1. _________________ 2. ___________________ 3. ______________________
Do you regularly watch the Local News: _______________________ National News: __________________________
31. Are you Married: ___ For how many years: _____; Divorced? _____ Widowed? _____ Single? _____________
If you are/were married, what is/was your spouse's:
Name: ___________________________ Occupation: _______________________________________________________
Educational level: ____________________________________________________________________________________
Political Party Preference: ____________________________________________________________________________
Religious Affiliation: _________________________________________________________________________________
32. How many children do you have: ____
Boys: Age 1: ___; 2: ___; 3: ___; 4: ___; 5: ___ 6: ___ Girls: 1: ___; 2: ___; 3: ___; 4: ___; 5: ___ 6: ___
Occupations: ________________________________________________________________________________________
33. Are people you usually run into in your neighborhood: All White ___ All Black ___ Both Black and White ____
34. Is there any other information that you believe might be important for the Court or for the lawyers to know about you as a potential juror:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
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________________________________ _________________________________ ___________________
Juror please sign full name here Print Name Date signed

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