CAR ACCIDENT, WEST PALM BEACH 33401 JUROR QUESTIONNAIRE

Your answers will be used for the sole purpose of selecting a jury in the case of (insert title of case). Your answers are confidential and will be used for no other purpose.

1. Name

2. Address

3. Age

4. Where were you born?

5. List all residences in which you have lived within the last five years.

6. Do you own your home, rent, share an apartment or live with relatives?

7. What is your marital status?

8. Have you ever been divorced, separated or widowed?

9. Do you have any siblings? If so, state their names, ages, residence and occupation.

10. What is your educational background?

a. Grade School

b. High School Graduate?

c. High School Equivalency

d. Technical or Vocational School

e. Secretarial School

f. Business School

g. Community College

h. Four-Year College

i. Post-Graduate Studies

11. If you attended a four-year college, when did you attend and what college did you attend?

12. What was your major subject?

13. Why did you decide to major in that subject?

14. Do you have any background in medicine? If so, give details.

15. What is your present occupation?

16. What are your job duties?

17. Do you have a specific job title?

18. If you are retired, what was your job before retirement?

19. Do you have any physical disabilities?

20. If so, what is the disability and how does it manifest itself?

21. Are you a salaried or hourly employee?

22. Do you have any management or administrative authority in your job?

23. If so, over how many employees?

24. List all prior employment positions held after completion of your schooling

25. If you are married, what kind of work does your spouse do?

26. What are his or her duties?

27. If your spouse is retired, what job did he or she have before retirement?

28. Did you serve in the military?

29. Did your spouse ever serve in the military?

30. If so, what was your/your spouse's rank, where did you/your spouse serve, and how many years did you/your spouse serve?

3l. Has any member of your family ever been involved in litigation? If so, please explain.

32. Was that litigation ever brought to West Palm Beach car accident trial?

33. If so, what was the result?

34. Did you sit in on the West Palm Beach car accident trial?

35. Have you ever hired an attorney?

36. If so, for what purpose?

37. Have you ever been a party to a litigation?

38. If so, give details.

39. Was that litigation ever brought to West Palm Beach car accident trial?

40. If so, what was the result?
41. Have you ever been involved in an automobile accident? If so, give details.

43. If so, what was the result?

44. Did you make any claim against any person as a result of that accident?

45. If so, what was the result?

46. Have you or any member of your family ever been involved in the insurance or claims industry?

47. If so, give details.

48. Have you or any member of your family ever been involved in the medical field (physician, nurse, psychiatrist, chiropractor, technician)?

49. Have you or any member of your family been involved in an occupation such as economist, actuary or accountant? If so, give details.

50. Do you have any children?

51. If so, are they living at home?

52. If so, list their ages and sex.

53. For each child list:

a. Educational background

b. Employment position

c. Medical background _
54. Do you read:

a. Newspapers

b. Books

c. Magazines

55. What newspapers do you subscribe to?

56. What magazines do you subscribe to?

57. What books have you recently read?

58. Do you watch television?

59. About how many hours per week do you watch television?

60. List the last few movies you have seen in a movie theater.

61. What is your favorite television program?

62. Do you watch the news on T.V.?

63. Do you watch local news, national news or both?

64. Do you belong to any civic, social or professional orgaruzations?

65. If so, what organizations do you belong to?

66. Do you have any principles or beliefs, either religious, ethical, moral or political, that would affect your ability to serve as a fair and impartial juror in this case?

67. If so, please identify with as much detail as possible how and why you feel such beliefs would affect your ability to serve as a fair and impartial juror.

68. Have you ever served on a jury before?

69. If so, was it a civil or a criminal case?

70. In which court?

71. What was the outcome of the case?

72. Who was the judge?

73. Regarding thermography, magnetic resonance imaging and/or TMJ,

a. Have you ever heard of thermography or a thermogram?

b. If so, what do you know about thermography?

c. Have you ever heard of magnetic resonance imaging or MRI?

d. If so, what do you know about MRI?

e. Have you ever heard of temporomandibular joint syndrome or TMJ?

f. If so, what do you know about TMJ?

g. Do you have any preconceived thoughts, notions or opinions about the scientific validity or invalidity of (list diagnostic tests applicable to the case)?

74. Have you ever heard the term "whiplash" injury?

75. If so, please explain your understanding of that injury.

76. Have you ever heard the term "soft tissue injury"?

77. If so, please explain your understanding of that term.

78. Have you ever heard the term "loss of consortium"?

79. If so, please give your understanding of that term.

80. Explain your understanding of the civil justice system

81. Do you have any particular criticisms or problems with the current civil justice system?

82. What do you think of lawyers who represent West Palm Beach car accident Plaintiff s in personal injury cases?

83. What do you think of lawyers who represent defendants in personal injury cases?