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Juror No.: ___________
UNITED STATES DISTRICT COURT
JUROR QUESTIONNAIRE
[CONFIDENTIAL]
In an effort to select fair and impartial juries, your cooperation is needed in
answering the following questions. The information that you provide will be used by the
judge and lawyers during the impaneling of a jury. Be sure to sign and date the
questionnaire. It should then be returned to the court in the enclosed envelope within
five (5) days.
This questionnaire is only provided to attorneys and their agents who are actually
involved in cases scheduled for trial. Those persons shall not disclose the information
you provide, nor may they provide the information to anyone not involved as an attorney
or authorized representative. It is important that you complete this entire questionnaire.
If you do not answer any of the questions, the court may instead individually question
you during the jury selection process about matters not completed.
PERSONAL IDENTIFICATION
(1) Name: ___________________________________________ Male G Female G
(2) Address: ____________________________________________________________
(3) City: ____________________________________________________________
(4) State: __________________________________________ Zip:_____________
(5) Age: ______________
(If you are 70 years or older and wish to be excused, YOU MUST attach a letter requesting an excuse
and you may stop completing this form. If you are requesting to be excused/deferred for any other
reason, YOU MUST include a letter setting forth the reason in detail and YOU MUST complete this
questionnaire form. NOTE: IF YOU WISH TO BE EXCUSED DUE TO PHYSICAL OR MENTAL
INFIRMITY, YOU MUST ENCLOSE A LETTER SETTING FORTH THE PHYSICAL OR
MENTAL CONDITION.
(6) Place of birth:________________________________________________________
(7) Do you consider yourself: G Caucasian, G African-American, G Asian/Asian
American, G Native American, G Hispanic, G Other:_________________________
(8) Do you have any physical or mental problems that might interfere with your
service as a juror? G Yes G No
If yes, describe:__________________________________________________________
(9) Are you taking any medications which by law must be prescribed by a
physician? G Yes G No
If yes, describe:__________________________________________________________
________________________________________________________________________
(10) Have you or any member of your family ever had a problem which you
attribute to drugs or alcohol? G Yes G No
If yes, please explain: ____________________________________________________
________________________________________________________________________
(11) Have you ever received or applied for any of the following benefits?
G veteran’s benefits, G social security benefits, G welfare benefits, G A.F.D.C. (Aid
to families with dependent children), G unemployment benefits or compensation,
G basic education grant, G C.E.T.A. benefits, G educational scholarships, G any
other type of federal, state or county benefits.
RESIDENCE
(12) City/Town:____________________________ County:______________________
(13) Do you: G own home, G rent home, G rent apartment, G live with
parents/relative or, G live with friends?
(14) Is your current address in a: G rural or G urban area?
(15) How long have you lived at your current address? Years _____ Months _____
(16) What other addresses have you had in the last 5 years?
________________________________________________________________________
________________________________________________________________________
(17) Have you ever lived outside of the southeastern United States? (i.e., Alabama,
Mississippi, Georgia, Florida, North Carolina, South Carolina, Tennessee,
Kentucky, or Louisiana) G Yes G No
If yes, where and when? __________________________________________________
_______________________________________________________________________
(18) Estimated number of miles ROUND TRIP from your home to the courthouse
to which you are summoned: _______________ miles
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MARITAL STATUS
(19) G Never married G Married to your current spouse for _____ years
G Separated G Divorced in _____
G Widowed in _____
CURRENT SPOUSE
(20) Spouse’s name: _________________________________________ Age: _______
(21) Spouse’s occupation:
________________________________________________________________________
(22) Spouse’s place of work and business telephone:
________________________________________________________________________
(23) Spouse’s job description:
________________________________________________________________________
(24) Years spouse employed in present job:
________________________________________________________________________
(25) Spouse’s highest education level completed
________________________________________________________________________
CHILDREN
DO NOT LIST NAMES
(26) Number of children: _____ boys, _____ girls
(27) List each child’s (a) age, (b) occupation, (c) place of employment or school, and
(d) city of residence:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
(28) Have you or any member of your family been educated through “home
schooling”? G Yes G No If yes, please give:
Person’s relationship to you:_______________________________________________
Number of years educated through home schooling: ___________________________
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SIBLINGS
DO NOT LIST NAMES
(29) Number of siblings: ________ brothers ________ sisters
(30) List each sibling’s (a) age, (b) occupation, (c) place of employment or school,
and (d) city of residence:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
EDUCATION
(31) Last year of school completed: G elementary/grade, G junior high, G high
school, G junior college, G vocational degree, G undergraduate degree, G graduate
work, G postgraduate work, G other:
(32) Major area of study:
_______________________________________________________________________
(33) Are you currently attending school? G Yes G No If yes, where?
________________________________________________________________________
________________________________________________________________________
EMPLOYMENT
(34) Are you presently employed? G Yes G No
Your occupation: (If retired, your occupation prior to retirement)
________________________________________________________________________
(35) Place of employment and job description:
________________________________________________________________________
________________________________________________________________________
(36) Type of business:
_______________________________________________________________________
(37) Daily shift hours: FROM: _____ TO: _____ Regular days off: ____________
(38) Total hours worked each week: _____________________
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(39) Are you a salaried employee of the U.S. Government? G Yes G No
(40) Years employed in present job: _______________
(41) Do you supervise others at this job? G Yes G No If yes, how many?______
(42) Do you have any other jobs? G Yes G No Describe what you do and place of
employment.____________________________________________________________
________________________________________________________________________
(43) What was your prior full-time occupation, if any? (Include job description
and place of work).
________________________________________________________________________
________________________________________________________________________
(44) To which professional or occupational organizations do you belong?
________________________________________________________________________
PAST JURY SERVICE
(45) Have you ever served on a trial jury? G Yes G No
If yes, when, where and how many times?
________________________________________________________________________
________________________________________________________________________
(46) Have you ever served on a grand jury? G Yes G No
If yes, when, where and how many times? ___________________________________
________________________________________________________________________
(47) Was your jury service: G criminal, G civil, G both
(48) How do you feel about your experience?
________________________________________________________________________
LEGAL INVOLVEMENT
(49) Are you or any member of your family involved in any action currently
pending in court? G Yes G No
If yes, where? _______________________________________________________
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(50) Have you ever been convicted of or pled guilty or nolo contendere to a felony
charge? (A felony charge is a crime for which the punishment could be a year or
more in prison). G Yes G No
If yes, give details: _______________________________________________________
________________________________________________________________________
________________________________________________________________________
(51) Have you or any member of your family ever been arrested or charged with a
criminal offense? G Yes G No If yes, please give:
Person’s relationship to you _______________________________________________
Offense in which person was charged _______________________________________
Year when arrest or charge was made _______________________________________
Outcome of arrest or charge _______________________________________________
(52) Have you or any member of your family ever been a victim of a crime?
G Yes G No If yes, please give:
Person’s relationship to you: ______________________________________________
Describe incident: _______________________________________________________
(53) Have you or any member of your family ever sued or been sued by anyone in
court? G Yes G No If yes, please give:
Describe lawsuit: ________________________________________________________
Give outcome: __________________________________________________________
(54) Have you or any member of your family ever filed a claim of discrimination?
G Yes G No If yes, please:
Describe claim: __________________________________________________________
Give outcome: ___________________________________________________________
(55) Have you or any member of your family ever had a claim of discrimination
filed against you, him or her? G Yes G No If yes, please:
Describe claim:_________________________________________________________
Give outcome: __________________________________________________________
(56) Have you or any member of your family ever filed for bankruptcy?
G Yes G No If yes, please:
Describe type of bankruptcy: ______________________________________________
Give outcome: ___________________________________________________________
(57) Have you or any member of your family consulted with a lawyer in the last five
years? G Yes G No If yes, for what reason?
(58) Have you ever appeared as a witness before a grand jury? G Yes G No
If yes, where and when? __________________________________________________
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(59) Have you ever appeared as a witness in a criminal or civil case? G Yes G No
If yes, when, where and for which type: _____________________________________
________________________________________________________________________
(60) Have you ever given a deposition (a statement under oath) in a legal
proceeding? G Yes G No
MILITARY SERVICE
(61) Have you ever served in the military? G Yes G No If yes:
What branch? ___________________________________________________________
What was your main occupation while in the service? __________________________
What was your highest rank? ______________________________________________
How long did you serve? __________________________________________________
Nature of your discharge? G Honorable G Dishonorable G Less than honorable
LAW ENFORCEMENT
(62) Have you ever worked in a law enforcement related job, such as police, sheriff,
trooper, prison guard or military police? G Yes G No
If yes, what type job? ____________________________________________________
PERSONAL INTEREST
(63) List any hobbies, spare-time activities, outside interests:
________________________________________________________________________
(64) What newspaper do you read most often?
________________________________________________________________________
(65) Do you subscribe? G Yes G No Sunday subscription only G Yes G No
(66) How often do you read it? G once a week, G 2-3 times a week, G 4 or more
times a week, G every day, G only when something special is reported, G Sunday
only
(67) What other newspapers do you read?
________________________________________________________________________
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(68) What television programs do you watch regularly?
________________________________________________________________________
_______________________________________________________________________
(69) How many times a week do you watch television news?
________________________________________________________________________
(70) What is your favorite radio station? _____________________________________
(71) Do you ever listen to “talk radio” programs? G Yes G No If yes, list the ones
you listen to most often: __________________________________________________
(72) List the magazines and periodicals you read:
________________________________________________________________________
________________________________________________________________________
(73) Are there any bumper stickers on the car that you or your spouse drive?
G Yes G No If yes, what do they say?
________________________________________________________________________
(74) Do you have a personalized license plate? G Yes G No
If yes, what is it and what does it mean: _____________________________________
________________________________________________________________________
(75) Do you have a home computer? G Yes G No
If yes, how often do you use it? ____________________________________________
(76) Do you have internet access? G Yes G No
If yes, how often do you use it? ____________________________________________
(77) What websites do you regularly visit?
________________________________________________________________________
(78) Do you have email? G Yes G No
If yes, how often do you use it? ____________________________________________
(79) Do you have a Personal Digital Assistant (PDA)? G Yes G No
If yes, how often do you use it? ____________________________________________
(80) Do you have a cell phone? G Yes G No
If yes, how often do you use it? ____________________________________________
(81) Do you attend church, synagogue, or other religious facility once a month or
more often? G Yes G No
If yes, name of church, synagogue or other facility: ___________________________
________________________________________________________________________
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(82) Please list any social, professional, civic, victim or civil liberties organizations
that you are a member of:
________________________________________________________________________
________________________________________________________________________
(83) Are you or any member of your family a member of any group which
encourages strict enforcement of criminal laws or modification of our present laws
such as Mothers Against Drunk Driving (MADD), Citizens Against Violence (CAV),
etc.? G Yes G No
(84) Have you ever been employed or volunteered your time in a social work
related job? G Yes G No
If yes, please describe: ___________________________________________________
________________________________________________________________________
(85) Do you regularly volunteer? G Yes G No
If yes, please describe: ___________________________________________________
________________________________________________________________________
(86) Do you smoke? G Yes G No
If yes, do you need to smoke more often than every two hours? _________________
(87) Do you generally G respect or G not respect the Judicial System?
(88) Is there any additional information about you that the court should know?
G Yes G No
If yes, please explain: ____________________________________________________
________________________________________________________________________
________________________________________________________________________
UNDER PENALTY OF PERJURY, I DO HEREBY CERTIFY THAT TO
THE BEST OF MY KNOWLEDGE AND BELIEF, ALL OF THE
ANSWERS HEREIN GIVEN ARE TRUE AND CORRECT.
___________________________________
(SIGNATURE)
___________________________________
(Date)
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