WEST PALM BEACH CAR ACCIDENT FLORIDA JURY QUESTIONNAIRE

This is a [description of the case].

Thank you for coming to court as a potential juror. Before the case can start, a jury must be selected. The judge and the lawyers 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 certain issues 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 view 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.

Please respond to the following questions as completely as possible. 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 the sheet of paper attached.

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.

Name:

Juror Number:

1. Age: Sex: Male____ Female_____ Race/Ethnicity:

2. Do you speak and understand English?
_____ Yes _____ No

3. Do you speak any other languages besides English?
_____ Yes _____ No

If YES, what other languages:

How long have you lived in [state]?

5. Neighborhood or community where you currently live: ____________________
How long have you lived there? ________

6. Where else have you lived (place and dates)?

Where were you born?

7. Do you currently own or rent your home?
Own _____ Rent_____ Other: (explain)
When was your house or apartment where you currently live built?

8. Have you ever owned any property that you rented to someone else?
____ Yes, now _____ Yes, in the past ____ No

If YES, please describe when you rented the property, to whom you rented the property and the type of property (a house, an apartment building, etc.).
9. Do you own, lease or regularly drive an automobile? If so, set forth make and model

____ Yes _____ No

10. Your employment status:
____ Currently employed full-time
____ Currently employed part-time
____ Unemployed, looking for work since _______________ (date)
____ Unemployed, not looking for work since _______________(date)
____ Full-time homemaker
____ Full-time student
____ Retired since _______________ (date)
____ Disabled since _______________ (date)
____ Other (specify) __________________________________________________

If currently employed:
Your Occupation:
Employer: For how long: _____ Number of employees at your work ____
Your job responsibilities:
Do you supervise others:_____ Yes _____ No If YES, how many:
Do you have any responsibility for hiring or firing: _____ Yes _____ No
Are you looking to change your current employment:_____ Yes _____ No
If YES, why:
How satisfied are you with your current work situation?
_____Very satisfied _____Not at all satisfied
_____Somewhat satisfied _____Not Working

11. If you are not currently employed:
Your last employer: For how long: Your occupation:
Number of employees at your last place of work:
Your job responsibilities:
Did you supervise others
_____ Yes _____ No If YES, how many?
Did you have any responsibilities for hiring or firing?
_____ Yes _____ No
Reason for leaving:

12. Please state any past occupations or types of work and employers. If retired or disabled, indicate your occupations prior to retirement or disability. Briefly describe each job.
Occupation/Employer Dates Job Description

13. Please describe your education:

School Degree/Certificate Area of Study Dates

What were your favorite classes in school?

14. Do you hold any professional or vocational licenses or certificates? _____ Yes _____ No
If YES, specify:
15. Do you have any special training or skills?

16. Do you plan to attend or are you currently attending school?
_____ Yes _____ No
If YES, please explain:

17. Your marital status:
Single and never married
Currently married and have been for _____ years
Single, living with significant other for _____ years
Single, but married in the past for _____ years
Widowed/widower, married in the past for _____ years
Other:
How many times have you been married?

18. Please provide the following information about your spouse or significant other:
a. Current employment status of your spouse or significant other?
Currently employed full-time Currently employed part-time
Unemployed, looking for work Unemployed, not looking for work
Full-time homemaker Retired since (date)
Full-time student Disabled since (date)
Other (specify: )
b. Current occupation: Employer:
number of years employed: _________
c. If retired or not currently employed, what was his/her:
Past occupation: Past employer:
number of years employed:_________
number of years since he/she stopped working: _________
d. Education of your spouse/significant other:

School Degree/Certificate Area of Study Dates

Does he/she hold any professional or vocational licenses or certifications?
_____ Yes _____ No
If YES, specify:

e. Age of your spouse/significant other: years
f. How long have you been together as a couple? years

19. Occupations of your parents or other persons who raised you? (List even if retired or deceased)
Mother: Father:
Other person(s) - Who/Occupation:

a. If you, your current spouse or a person with whom you currently live has ever served in the military, please list for each the branch of the service and dates of service:

b. If you have children, please state:

Does child Spouse’s
Sex Age live w/ you? Education Occupation Occupation

20. Please indicate the following information for each adult (other than your spouse/partner) who lives in your household on a regular basis, even if not living there full-time.

Person’s Relationship Age/ Occupation Length of
to you Sex and Employer Employment

21. Have you ever been self-employed or owned a business?
_____ Yes _____ No
If YES, how many employees? _____
What type of business?
How long were you in this business?
Do you currently own the business? ____ Yes _____ No
If NO, why not?

22. Have you or any family members ever had any educational or job-related training or experience in any of the following fields:

Yes, Self Yes, Family No

Law ________ __________ ______
Healthcare ________ __________ ______
Public health ________ __________ ______
Medicine ________ __________ ______
Automobile mechanics/repairs ________ __________ ______
Insurance ________ __________ ______
Social Work ________ __________ ______
Education ________ __________ ______
Engineering ________ __________ ______
Product Safety ________ __________ ______

a. If YES to the previous question, please explain:

Please list all social, civic, religious, or other clubs or organizations to which you belong, or in which you participate. Please list leadership roles, if any:

23. Have you or any family members ever worked for:

Yes, Self Yes, Family No
A law firm or lawyer ________ __________ ______
The court system ________ __________ ______
The legislature ________ __________ ______
An automobile manufacturer,
leasing company, car dealership ________ __________ ______
An insurance agency ________ __________ ______

If YES, please explain:

24. Have you ever worked for a large corporation?
_____ Yes, now _____ Yes, only in the past _____ No

25. Have you had any first-hand experience or dealings with a large corporation?
____ Yes ____ No
If YES, was your experience generally positive or negative?
____ Positive ____ Negative _____ Neither
Please explain your response: _______________________________________________

26. Have you or anyone close to you ever been injured in an accident?
_____ Yes, myself _____ Yes, someone else _____ Yes, both _____ No
If YES, please describe who it was, the nature of the injury and what happened.

27. Do you know anyone (including yourself) who has been involved in a lawsuit involving personal injuries?
Yes No

If YES, please describe who it was and the lawsuit:
28. Do you have any concerns about your health?

_____ Yes _____ No
If YES, please describe what your concerns are.

29. Do you have any concerns about your family members’ health?
_____ Yes _____ No
If YES, please describe whose health and what your concerns are.

30. Have you read or heard anything in the media or in conversation about the permanent health risks associated with neck and back injuries?
Yes No
If YES, what have you read or heard?

31. Have you formed any impression or do you have any opinion about the permanent health risks associated with neck and back injuries?

____ Yes _____ No

If YES, what is your impression or opinion:

32. Have you read or heard anything in the media or in conversation about this lawsuit?
Yes No
If YES, what have you read or heard?

33. Have you formed any strong impression or do you have any strong opinion/feeling about any of the companies listed below? [list all the defendants]
Yes No
Yes No

34. If you indicated that you have an impression/opinion/feeling about any one of the companies listed above, please explain:

35. Have you formed any strong impression or do you have any strong opinion/feeling about the amount of government regulation of automobile manufacturers?
_____ Yes _____ No

If YES, what is your impression/opinion/feeling?

36. Do you agree or disagree with each of the following statements?
a. Without a threat of multimillion dollar lawsuits, corporations would knowingly sacrifice the safety of their workers and the public in order to protect their profits.
___ Agree ___ Unsure ___ Disagree
b. When I hear that an individual has filed a lawsuit against a corporation, I usually think the corporation deserves blame and the individual deserves compensation.
___ Agree ___ Unsure ___ Disagree
c. It is not fair to judge a company’s health and safety standards in the past by what is known about health and safety today.
___ Agree ___ Unsure ___ Disagree

37. Do you know any attorneys, judges, or people involved in the court or legal system?
_____ Yes _____ No
If YES, please explain:

38. Have you ever served on a jury?
_____ Yes _____ No If YES:
When: Civil case(s):
Criminal case(s):
Type(s) of lawsuit(s):
For each case, did the jury reach a verdict?
Were you the foreperson? _____ Yes _____ No
How would you describe your experience(s):

39. Have you or anyone close to you ever participated in the legal system, as a party, a witness, or as an expert?
_____ Yes _____ No If YES, please explain:

40. Have you or has anyone close to you ever sued or been sued?
_____ Yes _____ No
If YES, please explain:

41. Have you ever thought of suing someone or some entity but did not?
_____ Yes _____ No
If YES, please explain:

42. In general, do you believe jury monetary awards today are:
___ Too high ____ Too low ____ About right ____ No opinion

43. How frequently do you follow the news, either on radio, TV or in the newspaper?
Several times a day Sources:
Once a day
Occasionally
Almost never

44. What newspapers and magazines do you read regularly?

45. What are your favorite television shows?

46. Do you use a computer?
Yes, at home At home and at work
Yes, at work No
If YES, for what purposes?
Home:
Work:
IF YES: How many hours per week do you spend on the Internet?

47. Are you generally satisfied with your financial condition?
____ Very satisfied ____ Somewhat satisfied ____ Not satisfied

48. Which of the following do you tend to consult and rely upon when you are making an important personal decision? Check all that apply.

Myself My family
My friends Experts
Written materials Religious Figure/church/prayer
Other

49. As a juror, after rendering a verdict for or against any party involved in this lawsuit, do you believe you will be judged any differently upon returning to your community?
____ Yes ____ No
Please explain:

50. Describe any problem (vision, hearing, or other medical problems) that may affect your jury service:

51. Do you have any philosophical, religious or other beliefs that would prevent you from sitting in judgment on this case? _____ Yes _____ No If YES, please explain:

52. Is there any other matter that could affect your ability to be a fair and impartial juror in this case?
_____ Yes _____ No If YES, please explain:

53. Do you have any initial reaction to this case based on what you have read or been told?
_____ Yes _____ No If YES, please explain:

54. Do you recognize or think you might know any of the entities or people listed on Attachment A?
_____ Yes _____ No
If YES, please write the name(s) here and explain:
I, _________________________________, DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF [INSERT] 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

Space for further explanation of any questions. Please note question number.