Form Mc 001 – Fill Out and Use This PDF

This Juror Questionnaire has been drafted under the authority of Code of Civil Procedure section 205(c)-(d) and is intended to expedite jury selection. It is not intended to alter statutes or rules governing the authority of the court or the role of counsel during voir dire.

Sec. 2. Use Notes for Courts

A. General

This Juror Questionnaire is intended for use in the court's discretion in appropriate civil cases. Its use in cases of brief duration may not be appropriate. Particular kinds of cases may require that this questionnaire be altered or augmented. The Personal Injury Supplement is intended to be used along with the General Questions in personal injury actions. Judges, in their own discretion, must determine what additional kinds of inquiry are appropriate in any given case.

B. Pre–Voir Dire Conference

The court should confer with counsel about voir dire before a jury panel is called. At this conference, the court may establish (1) guidelines for the use of the Juror Questionnaire, (2) any supplemental questions to be propounded to the panel by questionnaire, (3) the extent of the court's oral inquiry of the panel, and (4) the extent of oral questioning by counsel. Proposed supplemental questions drafted by counsel should be filed and served at least three court days before the pre–voir dire conference. Arrangements for duplication of completed questionnaires should be confirmed. The parties should share the cost of duplication.

C. Introduction of Questionnaire to Prospective Jurors

It is suggested that the Juror Questionnaire be used after the court has given its customary introductory remarks and any additional instructions that the court deems appropriate. The court also may wish to tell the panel members that a questionnaire will be used, to encourage complete answers, and to remind them that their answers will be given under penalty of perjury. In introducing the questionnaire, the court should instruct prospective jurors how to proceed if they have difficulty reading or filling out the form.

The court could direct that the Juror Questionnaire be given to prospective jurors by the jury commissioner in the jury assembly room. However, this procedure ordinarily will mean that jurors are not given complete instructions about the type of case they will hear or the identity of participants and witnesses. In addition, jurors who fill out the form before appearing in the trial court may not clearly understand that their answers are given under penalty of perjury. For these reasons, and to avoid the need to have jurors fill out supplemental questionnaires once they have been sent to the trial court, it is strongly recommended that the Juror Questionnaire be used in the trial court setting.

Thank you for coming to court as a potential juror. Before the case can start, a jury must be selected. The judge and the people involved in the case need to know something about you in order to select jurors who can be fair to both sides.

Everyone has attitudes and opinions that are shaped by their life experiences. Sometimes these experiences can make it difficult to look at a certain issue in an unbiased and unemotional way. As a juror, you must return a verdict based on the law and on the facts proved in court, not on emotion or on other views not supported by the evidence. The judge will give you instructions on the law and on how you should go about deciding the case. You must listen to and follow the judge's instructions.

The questions on this form are designed to help the court and the lawyers learn something about your background and your views on issues that may be related to this case. The questions are asked not to invade your privacy, but to make sure that you can be a fair and impartial juror. If there is any reason why you might not be able to give both sides a fair trial in this case, it is important that you say so.

The judge has decided to use this form to save time and to give you a chance to tell the court and the lawyers about yourself.

In portions of this form, you will see the term "significant personal relationship." That term means a former spouse, domestic partner, life partner, or anyone with whom you have an influential or intimate relationship that you would characterize as important.

If there is anything you do not want to talk about in open court, please circle the question number. After you have finished the questionnaire, let the clerk know that you have circled one or more question numbers.

Do not write on the back of any page. Use an additional sheet of paper.

If you are called to the jury box, your answers to this questionnaire become a matter of public record, just as if you had answered the questions aloud in the courtroom.

If you have trouble reading, understanding, or filling out this form, please let the court clerk know.

PLEASE REMEMBER THAT YOU ARE ANSWERING THESE QUESTIONS UNDER PENALTY OF PERJURY. YOUR ANSWERS MUST BE TRUE AND COMPLETE. THANK YOU FOR YOUR HELP IN SELECTING A FAIR JURY.

PLEASE PRINT ALL ANSWERS LEGIBLY

FULL NAME:

1.1DATE AND PLACE OF BIRTH:

1.2AREA, NEIGHBORHOOD, OR COMMUNITY IN THIS COUNTY WHERE YOU CURRENTLY LIVE (DO NOT GIVE YOUR ADDRESS):

1.3 AREA, NEIGHBORHOOD, OR COMMUNITY WHERE YOU HAVE LIVED IN THE PAST 10 YEARS (AND DATES):

1.4 WHAT IS THE HIGHEST LEVEL OF EDUCATION YOU COMPLETED?

1.5 IF YOU PLAN TO ATTEND OR ARE CURRENTLY ATTENDING SCHOOL, DESCRIBE:

1.6IF YOU HAVE TAKEN ANY COURSES OR HAD ANY TRAINING IN MEDICINE OR OTHER HEALTH CARE FIELD, DESCRIBE:

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1.7 IF YOU HAVE TAKEN ANY COURSES OR HAD ANY TRAINING IN LAW OR A RELATED SUBJECT, DESCRIBE:

1.8EDUCATIONAL BACKGROUND OF ANY OTHER ADULT WHO LIVES IN YOUR HOME, INCLUDING ANY DEGREES OR CERTIFICATES EARNED:

1.9YOUR PRESENT EMPLOYMENT STATUS (CHECK ALL THAT APPLY):

1.10YOUR CURRENT OR MOST RECENT OCCUPATION:

1.11NAME OF YOUR CURRENT OR MOST RECENT EMPLOYER OR, IF A STUDENT, YOUR SCHOOL:

1.12WHAT ARE YOUR SPECIFIC DUTIES AND RESPONSIBILITIES ON THE JOB?

1.16 ALL OTHER EMPLOYMENT YOU HAVE HAD (AND FOR HOW LONG):

1.17ALL FULL-TIME EMPLOYMENT OF YOUR SPOUSE OR ANY PERSON WITH WHOM YOU HAVE A SIGNIFICANT PERSONAL RELATIONSHIP (AND FOR HOW LONG):

1.18WHAT ARE/WERE THE OCCUPATIONS OF YOUR PARENTS? (IF RETIRED, WHAT DID THEY DO BEFORE?)

MOTHER:

FATHER:

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1.19 IF YOU HAVE CHILDREN, PLEASE LIST (INCLUDING ANY CHILDREN WHO DO NOT CURRENTLY LIVE WITH YOU):

		DOES CHILD LIVE
SEX	AGE	WITH YOU?	EDUCATION	OCCUPATION

1.20IF YOU OR YOUR CURRENT SPOUSE OR PERSON WITH WHOM YOU HAVE A SIGNIFICANT PERSONAL RELATIONSHIP HAS EVER SERVED IN THE MILITARY, PLEASE LIST FOR EACH THE BRANCH OF SERVICE AND DATES OF SERVICE:

1.21WHAT SOCIAL, CIVIC, PROFESSIONAL, TRADE, OR OTHER ORGANIZATIONS ARE YOU AFFILIATED WITH?

1.22DESCRIBE ANY OFFICES YOU HAVE HELD IN ORGANIZATIONS LISTED ABOVE:

1.23DO YOU KNOW ANYONE ON THIS JURY PANEL?

1.24ON HOW MANY CASES HAVE YOU SERVED ON A JURY? WHERE DID YOU SERVE ON A JURY?

WHAT KINDS OF CASES DID YOU HEAR WHILE SERVING ON A JURY?

IN HOW MANY OF THOSE CASES DID THE JURY REACH A VERDICT?

IN HOW MANY OF THOSE CASES DID YOU SERVE AS THE JURY FOREPERSON?

WAS YOUR JURY SERVICE A POSITIVE OR NEGATIVE EXPERIENCE?

1.25 IF YOU HAVE EVER BEEN TO COURT FOR ANY OTHER REASON (EXCLUDING DIVORCE), EXPLAIN:

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1.26IF YOU PERSONALLY KNOW ANY JUDGES OR ATTORNEYS OR COURT PERSONNEL, WHAT ARE THEIR NAMES AND RELATIONSHIP TO YOU?

1.27DESCRIBE ANY PROBLEMS (VISION, HEARING, OR OTHER MEDICAL PROBLEMS) THAT MAY AFFECT YOUR JURY SERVICE:

1.28IF YOU OR ANYONE CLOSE TO YOU HAS EVER MADE ANY TYPE OF CLAIM FOR DAMAGES, EXPLAIN:

1.29IF A CLAIM FOR MONEY DAMAGES HAS EVER BEEN MADE AGAINST YOU OR ANYONE CLOSE TO YOU, EXPLAIN THE CIRCUMSTANCES:

1.30 IF YOU OR ANYONE CLOSE TO YOU HAS EVER SUED OR BEEN SUED IN ANY TYPE OF LAWSUIT, EXPLAIN:

1.31 DO YOU FEEL THAT MONEY DAMAGES AWARDED IN LAWSUITS ARE (CHECK ONE):

1.32IF YOU HAVE ANY ETHICAL, RELIGIOUS, POLITICAL, OR OTHER BELIEFS THAT MAY PREVENT YOU FROM SERVING AS A JUROR, EXPLAIN:

1.33IF THERE IS ANY MATTER NOT COVERED BY THIS QUESTIONNAIRE THAT COULD AFFECT YOUR ABILITY TO BE A FAIR AND IMPARTIAL JUROR, EXPLAIN:

2.1IF YOU OR ANYONE CLOSE TO YOU HAS EVER BEEN INVOLVED IN AN ACCIDENT IN WHICH SOMEONE WAS INJURED, EXPLAIN:

2.2PLACE A CHECK MARK ON THE APPROPRIATE LINE(S) IF YOU OR ANYONE CLOSE TO YOU HAS EVER BEEN EMPLOYED IN ANY CAPACITY BY ANY OF THE FOLLOWING TYPES OF BUSINESSES:

YOURSELF OTHER PERSON

ANY COURT IN THE STATE OF CALIFORNIA

ATTORNEY, LAW FIRM, OR LAW OFFICE

CLAIMS ADJUSTMENT, EVALUATION, REVIEW, SETTLEMENT, OR INVESTIGATION

ACCIDENT INVESTIGATION OR LAW ENFORCEMENT

DISABILITY, HEALTH, LIFE, CASUALTY, OR ACCIDENTAL INJURY BENEFITS OR

PROGRAMS

ECONOMICS, ACTUARIAL, OR INVESTMENTS

HEALTH CARE DOCTOR, NURSING, HOSPITAL, DENTAL, PHYSICAL THERAPY,

PHARMACY, OR ANY RELATED FIELD

2.3IF YOU CHECKED ANY LINE IN THE PREVIOUS QUESTION (2.2), PLEASE STATE THE RELATIONSHIP OF THAT PERSON TO YOU, THE TYPE AND DETAILS OF THAT EMPLOYMENT, AND THE YEARS OF THAT EMPLOYMENT:

2.4DO YOU HAVE ANY BELIEFS AGAINST AWARDING DAMAGES FOR PERSONAL INJURY, PAIN, OR SUFFERING?

IF YES, EXPLAIN:

2.5DO YOU OR ANY MEMBERS OF YOUR IMMEDIATE FAMILY OR HOUSEHOLD SEE A DOCTOR OR OTHER MEDICAL PRACTITIONER REGULARLY FOR ANY CONTINUING MEDICAL PROBLEM?

IF YES, EXPLAIN:

I,	, DECLARE UNDER PENALTY OF PERJURY UNDER THE

LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING RESPONSES I HAVE GIVEN ON THIS JUROR QUESTIONNAIRE, AND ON ANY ATTACHED SHEETS, ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.

Date:

(SIGNATURE OF DECLARANT)