West Palm Beach car accident case General Juror Questionnaire

West Palm Beach car accident case General Juror Questionnaire

The purpose of this questionnaire is to assist the court in selecting juries. The questionnaire is being sent to you (a potential juror in the west palm beach car accident case) in advance of jury selection to save time during the jury selection process. It will only be used for jury selection and may not be made available to the pubic.
INSTRUCTIONS
1. Complete, sign, and return within 3 days of receipt to:
Clerk, County Circuit Court
Attn: Jury Administrator

2. Use a black pen.
Juror’s Name: (Print)
Mailing Address:
Permanent Address (If Different):
Telephone Numbers: Home: Work:
Do you (a potential juror in the west palm beach car accident case) rent or own (purchasing)? Years at this address:
Juror’s age:
How would you (a potential juror in the west palm beach car accident case) describe the condition of you (a potential juror in the west palm beach car accident case)r health?
If you (a potential juror in the west palm beach car accident case) have any physical or medical problems which would make jury duty difficult or which require accommodation, please explain them here:

1. Juror’s education: (please check most appropriate)
less than 6th grade
technical, business or two-year degree
more than 6th grade but no high school diploma
high school graduate
some college but no degree
four-year college degree in
post-graduate work or degree in
2. List any special training or skills you (a potential juror in the west palm beach car accident case) have:
3. What is you (a potential juror in the west palm beach car accident case) current job status? (Please check most appropriate answer)
working full-time unemployed homemaker
working part-time retired full-time student
4. Who is you (a potential juror in the west palm beach car accident case)r present (or most recent) employer?
5. What is you (a potential juror in the west palm beach car accident case)r present (most recent) job title?
6. Describe the duties of you (a potential juror in the west palm beach car accident case)r current (or most recent) job:
7. If retired, disabled, or unemployed, indicate the date of you (a potential juror in the west palm beach car accident case)r retirement or you (a potential juror in the west palm beach car accident case)r latest employment:
8. Has you (a potential juror in the west palm beach car accident case)r occupation changed in the last five years?
If yes, indicate all occupations held in the last five years:
9. List all other types of jobs you (a potential juror in the west palm beach car accident case) have had throughout you (a potential juror in the west palm beach car accident case)r life (not listed above):
10. Have you (a potential juror in the west palm beach car accident case) ever served in the military? If yes, indicate the following:
branch of service years of service
rank at discharge form of discharge
11. Juror’s marital status:
single, never married widow/widower
single but previously married for years other
currently married, have been for years
12. If currently married, provide the following information:
a. Spouse’s education:
b. Spouse’s present employment status:
c. Spouse’s present occupation and employer:
d. Other types of jobs you (a potential juror in the west palm beach car accident case)r spouse has held:
13. If you (a potential juror in the west palm beach car accident case) have children, please give their ages, gender, and occupations:
Some of the questions below refer to you (a potential juror in the west palm beach car accident case)r “family.” This is intended to include you (a potential juror in the west palm beach car accident case)r mother, father, sisters, brothers, children, and spouse.
14. Other than the military, have you (a potential juror in the west palm beach car accident case) or any member of you (a potential juror in the west palm beach car accident case)r family been employed by the United States government or any state or local government? yes no
If yes, who was so employed, when and where?
15. Have you (a potential juror in the west palm beach car accident case) or any member of you (a potential juror in the west palm beach car accident case)r family ever worked for a law enforcement organization?
yes no
If yes, who was so employed, when and where?
16. What are you (a potential juror in the west palm beach car accident case)r hobbies, special interests, recreational pastimes, and other spare-time activities, including sports?
17. What is/are you (a potential juror in the west palm beach car accident case)r primary source(s) of news?
TV Newspaper Radio
Magazines Other
What magazines and newspapers do you (a potential juror in the west palm beach car accident case) regularly read?
18. Have you (a potential juror in the west palm beach car accident case) ever been a member of a professional or job-related organization (including labor unions)? yes no
If yes, identify the organization(s)
19. What social, political, civic, religious, and other organizations do you (a potential juror in the west palm beach car accident case) belong to or are you (a potential juror in the west palm beach car accident case) associated with?
20. Are you (a potential juror in the west palm beach car accident case) or any member of you (a potential juror in the west palm beach car accident case)r family a member of any group which encourages strict enforcement of criminal laws or modification of our present laws such as Mothers Against Drunk Drivers (MADD), Citizens Against Violence (CAVE)?
yes no
If yes, identify the family member (by relationship) and the group to which he/she belongs:
21. Have you (a potential juror in the west palm beach car accident case) displayed any bumper stickers on you (a potential juror in the west palm beach car accident case)r automobile in the last twelve months?
yes no
If yes, please list each bumper sticker:
22. Have you (a potential juror in the west palm beach car accident case) or any member of you (a potential juror in the west palm beach car accident case)r family ever suffered long-term or permanent disability?
yes no
If yes, please explain:
23. Have you (a potential juror in the west palm beach car accident case) previously served on a jury? yes no
If so, what type of case was it? criminal civil
Was a verdict reached? yes no
What was the verdict?
Did anything happen during you (a potential juror in the west palm beach car accident case)r previous jury service which might affect you (a potential juror in the west palm beach car accident case)r ability to make a decision if you (a potential juror in the west palm beach car accident case) are selected as a juror during this term of court?
yes no
If yes, please explain
24. Have you (a potential juror in the west palm beach car accident case) ever been a witness in a civil or criminal trial?
yes no
If yes, please explain:
25. Have you (a potential juror in the west palm beach car accident case) or anyone in you (a potential juror in the west palm beach car accident case)r family ever been involved in a lawsuit, including a suit involving a worker’s compensation claim? yes no
If yes, indicate the following:
Family member involved: (relationship)
Was that person the plaintiff (person who sues) or the defendant?
What type of case was it? (example, auto accident)
Who was you (a potential juror in the west palm beach car accident case)r or you (a potential juror in the west palm beach car accident case)r family member’s lawyer?
26. Have you (a potential juror in the west palm beach car accident case) or any member of you (a potential juror in the west palm beach car accident case)r family ever complained to any seller or manufacturer that a product it sold or made was defective or unreasonably dangerous?
yes no
If yes, please explain.
27. Have you (a potential juror in the west palm beach car accident case) or a member of you (a potential juror in the west palm beach car accident case)r immediate family ever filed a claim with an insurance company (other than a health insurance claim)? yes no
If yes, what was the nature of the claim and when was it filed?
Was the claim paid? If not, how was the matter resolved?
28. Have you (a potential juror in the west palm beach car accident case), or any close friends or relatives, been the victim of a defective product?
yes no
If yes, please explain who the victim was and the type of product:
29. Have you (a potential juror in the west palm beach car accident case) or any close friends or relatives ever been a victim of medical malpractice or medical negligence?
yes no
If yes, please explain:
30. Have you (a potential juror in the west palm beach car accident case) or any family member ever been convicted of a crime other than a traffic offense?
yes no
If yes, please explain who was convicted of what crime.
If you (a potential juror in the west palm beach car accident case) were convicted of a crime, what was the nature of the crime charged?
Was the crime punishable by imprisonment for more than one year?
yes no
If yes, were you (a potential juror in the west palm beach car accident case)r civil rights restored and, if so, in what manner?
31. Have you (a potential juror in the west palm beach car accident case) or anyone in you (a potential juror in the west palm beach car accident case)r family ever worked for:
Yes No
A lawyer or law firm
An insurance company
The court system
A large corporation
A doctor, hospital, or
health care organization
32. Corporations have the same rights under the laws as any individual. Do you (a potential juror in the west palm beach car accident case) feel that you (a potential juror in the west palm beach car accident case) can be fair to both sides in a lawsuit that involves an individual on one side and a company or corporation on the other?
33. Would any personal experiences prevent you (a potential juror in the west palm beach car accident case) from being fair to both sides in a case involving a person with a personal injury or disability?
34. Jurors are often required to decide which witnesses to believe and which not to believe. In deciding believability, jurors may consider how the witnesses presented themselves, certain factors in the witnesses’ background, and many other factors. However, you (a potential juror in the west palm beach car accident case) may not judge believability of a witness simply based on that person’s occupation or position in life.
Understanding these rules, would you (a potential juror in the west palm beach car accident case) be able to judge the believability of physicians or expert witnesses by the same standard as any other witness?
yes, I can no, I cannot
35. Regardless of any opinion you (a potential juror in the west palm beach car accident case) may have concerning a particular law, would you (a potential juror in the west palm beach car accident case) be able to set aside you (a potential juror in the west palm beach car accident case)r feelings and follow the law as stated by the judge?
yes no
36. If you (a potential juror in the west palm beach car accident case) desire to do so, you (a potential juror in the west palm beach car accident case) may explain any of you (a potential juror in the west palm beach car accident case)r answers here:
37. Is there any additional information about you (a potential juror in the west palm beach car accident case) that the court should know?
Thank you (a potential juror in the west palm beach car accident case) again for you (a potential juror in the west palm beach car accident case)r cooperation. Please read the following and sign below.
The answers provided above are truthful and complete to the best of my ability. I understand that knowingly giving a false answer may subject me to the penalties for perjury.
SIGN HERE:
JUROR’S SIGNATURE
COMPLETE AND RETURN WITHIN 3 DAYS OF RECEIPT.