1. Name:
*
Juror ID #
*
Group #
*
Report Week Starting Date:
*
DOB:
*
Age:
Race / Ethnicity:
Alaska Natives
American Indian
Asian
Black or African Americans
Pacific Islander
Hispanic and Latino
White
Gender:
Male
Female
Non-Disclosed
2. City of residence:
Length of residence:
3. Current Occupation:
For how long?
4. Prior Occupation:
For how long?
5. List highest level of education reached:
Major and/or degree(s) (if applicable):
6
. Marital Status:
Number of children:
7. Occupations of adult children:
8. List other adults in your household and their occupations:
9. Have you ever served on a jury before?
No
Yes
Many
a. When & where?:
b. Was it civil or criminal? What was the case generally about?
Civil
Criminal
c. Without telling us what it was, did the jury reach a verdict?
Guilty
Not Guilty
Hung Jury
Settlement
d. Were you the foreperson?
Yes
No
Please fill in your juror experience below. Please duplicate as many times as necessary.
Jury Service: When and When? Was it Civil or Criminal? What was the case generally about? Without telling us what it was, did the jury reach a verdict? Were you the foreperson? Jury Service: When and When? Was it Civil or Criminal? What was the case generally about? Without telling us what it was, did the jury reach a verdict? Were you the foreperson? Jury Service: When and When? Was it Civil or Criminal? What was the case generally about? Without telling us what it was, did the jury reach a verdict? Were you the foreperson?
10. Have you or anyone close to you (relative, close friend or colleague, etc.), ever been
a.
The victim of or witness to a crime? If so, please describe::
b.
Accused of or convicted of a crime? If so, please describe:
c.
A party to or testified in a civil lawsuit? If so, please describe:
d.
Employed within the legal or court systems (law enforcement, attorney, probation, social services, corrections, etc.) or had any related training or experience? If so, please describe:
11. Do you know of any reason why you would not be able to be a fair and impartial juror?
12. Please provide any additional information below:
13. Please describe your reason if you wish to file a Hardship Request.
14
. I declare under penalty of perjury that the foregoing is true and correct to the best of my knowledge.
*
By submitting this form all answers will be sent to the Jury Services Unit. If you need to correct this form, you must complete a new form, in its entirety and submit.
Confidentiality Notice: Questionnaires will be destroyed if the prospective juror is not assigned to a jury trial department.