Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-5_03-cv-03813/USCOURTS-cand-5_03-cv-03813-0/pdf.json

Nature of Suit Code: 440
Nature of Suit: Other Civil Rights
Cause of Action: 42:1983 Civil Rights Act

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JUROR QUESTIONNAIRE

PLEASE PRINT ALL ANSWERS LEGIBLY

FULL NAME ________________________________________________________

1. DATE AND PLACE OF BIRTH _____________________________________________

2. MARITAL STATUS:

G SINGLE AND NEVER MARRIED

G CURRENTLY MARRIED AND HAVE BEEN FOR ____ YEARS

G SINGLE BUT MARRIED IN THE PASSED FOR ____ YEARS

G SINGLE BUT LIVING WITH NON MARITAL MATE FOR ___ YEARS

G WIDOWED BUT MARRIED IN THE PAST FOR ____ YEARS

G OTHER (SPECIFY) _________________________________________________

ANY PRIOR MARRIAGES NOT COVERED BY THE ABOVE? YES [] NO []

3. AREA, NEIGHBORHOOD, OR COMMUNITY IN THIS COUNTY WHERE YOU

CURRENTLY LIVE (DO NOT GIVE ADDRESS): ______________________________

________________________________________________________________________

[] HOUSE [] APARTMENT [] OWN [] RENT

4. AREA, NEIGHBORHOOD, OR COMMUNITY WHERE YOU HAVE LIVED IN THE

PASSED 10 YEARS (AND DATES): _________________________________________

________________________________________________________________________

5. WHAT IS THE HIGHEST LEVEL OF EDUCATION YOU COMPLETED?

[] GRADE SCHOOL OR LESS [] SOME COLLEGE

[] SOME HIGH SCHOOL (MAJOR): _________________________

[] HIGH SCHOOL GRADUATE [] COLLEGE GRADUATE

[] OTHER (PLEASE EXPLAIN): (MAJOR): _________________________

___________________________ [] POST GRADUATE STUDY

___________________________ (MAJOR) : _________________________

___________________________ [] TECHNICAL, VOCATIONAL, OR 

BUSINESS SCHOOL (MAJOR) : ________

____________________________________

6. IF YOU PLAN TO ATTEND OR ARE CURRENTLY ATTENDING SCHOOL,

DESCRIBE: _____________________________________________________________

________________________________________________________________________

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7. IF YOU HAVE TAKEN ANY COURSE OR HAD ANY TRAINING IN MEDICINE,

PSYCHOLOGY, OTHER HEALTH CARE FIELD OR EDUCATION, DESCRIBE: ____

________________________________________________________________________

________________________________________________________________________

8. IF YOU HAVE TAKEN ANY COURSES OR HAD ANY TRAINING IN LAW OR

RELATED SUBJECT, DESCRIBE: __________________________________________

________________________________________________________________________

________________________________________________________________________

9. DID YOU HAVE A POSITIVE SCHOOL EXPERIENCE IN ELEMENTARY SCHOOL

[] YES [] NO, MIDDLE SCHOOL [] YES [] NO, HIGH SCHOOL [] YES [] NO

EXPLAIN _______________________________________________________________

________________________________________________________________________

10. DURING YOUR ACADEMIC CAREER DID YOU EVER HAVE A NEGATIVE OR

HARMFUL EXPERIENCE WITH A TEACHER? EXPLAIN: _____________________

________________________________________________________________________

________________________________________________________________________

11. DID YOU EVER FILE A GRIEVANCE AGAINST A SCHOOL, ADMINISTRATOR OR

TEACHER? EXPLAIN: ____________________________________________________

________________________________________________________________________

________________________________________________________________________

12. HAVE YOU OR ANYONE CLOSE TO YOU EVER BEEN ELIGIBLE FOR SPECIAL

EDUCATION AND RELATED SERVICES? [] YES [] NO EXPLAIN: _________

________________________________________________________________________

________________________________________________________________________

13. DOES ANY ONE CLOSE TO YOU HAVE SPECIAL NEEDS? [] YES [] NO

EXPLAIN: _______________________________________________________________

________________________________________________________________________

14. DO YOU KNOW ANYONE WITH AUTISM? [] YES [] NO

15. HAVE YOU EVER TAKEN OR PARTICIPATED IN A CERTIFICATION CLASS

REGARDING THE USE OF RESTRAINTS?

[] YES [] NO

IF SO, PLEASEDESCRIBE: _________________________________________________

__________________________________________________________________________

________________________________________________________________________

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16. IF YOU HAVE EVER IMPLEMENTED A PHYSICAL RESTRAINT UPON ANOTHER

PERSON, PLEASE DESCRIBE THE CIRCUMSTANCES INVOLVED. 

________________________________________________________________________

________________________________________________________________________

17. EDUCATIONAL BACKGROUND OF YOUR FORMER SPOUSE, INCLUDING ANY

DEGREES OR CERTIFICATES EARNED: ____________________________________

________________________________________________________________________

________________________________________________________________________

18. YOUR PRESENT EMPLOYMENT STATUS (CHECK ALL THAT APPLY):

[] EMPLOYED FULL-TIME [] RETIRED [] UNEMPLOYED, LOOKING FOR WORK

[] EMPLOYED PART-TIME [] STUDENT [] UNEMPLOYED, NOT LOOKING FOR

 WORK

[] HOMEMAKER

19. YOUR CURRENT OR MOST RECENT OCCUPATION: ________________________

________________________________________________________________________

20. NAME OF YOUR CURRENT OR MOST RECENT EMPLOYER OR, IF A STUDENT,

YOUR SCHOOL: _________________________________________________________

21. WHAT ARE YOUR SPECIFIC DUTIES AND RESPONSIBILITIES ON THE JOB? ___

________________________________________________________________________

________________________________________________________________________

22. DOES YOUR JOB INVOLVE SUPERVISING OTHER PEOPLE? [] YES [] NO

IFYES,APPROXIMATELYHOWMANY? _____________________________________

23. ARE YOU INVOLVED IN THE HIRING OR FIRING OF OTHER EMPLOYEES?

[] YES [] NO

24. ARE YOU INVOLVED IN EVALUATING THE JOB PERFORMANCE OF OTHER

EMPLOYEES? [] YES [] NO

25. ALLOTHERFULL-TIMEEMPLOYMENTYOUHAVEHAD(ANDFORHOWLONG):

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

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26. ALL FULL-TIME EMPLOYMENT OF YOUR SPOUSE/FORMER SPOUSE (AND FOR

HOW LONG): ____________________________________________________________

________________________________________________________________________

________________________________________________________________________

27. ALL FULL-TIME EMPLOYMENT OF ANY OTHER ADULT WHO LIVES IN YOUR

HOME (AND FOR HOW LONG): ___________________________________________

________________________________________________________________________

________________________________________________________________________

28. WHAT AREA WERE THE OCCUPATIONS OF YOUR PARENTS? (IF RETIRED,

WHAT DID THEY DO BEFORE?)

FATHER: _______________________________________________________________

________________________________________________________________________

MOTHER: _______________________________________________________________

________________________________________________________________________

29. IF YOU HAVE CHILDREN, PLEASE LIST (INCLUDING ANY CHILDREN WHO DO

NOT CURRENTLY LIVE WITH YOU):

GENDER __________, AGES __________, DO ANY CHILDREN LIVE WITH YOU

[] YES [] NO,

EDUCATION______________________________________________________________,

OCCUPATION ___________________________________________________________

30. IF YOU OR YOUR CURRENT SPOUSE OR PERSON WITH WHOM YOU

CURRENTLY LIVE WITH HAS EVER SERVED IN THE MILITARY, PLEASE LIST

BRANCH AND DATES OF SERVICE: _______________________________________

________________________________________________________________________

31. WHAT SOCIAL, CIVIC, PROFESSIONAL, TRADE OR OTHER ORGANIZATIONS

ARE YOU AFFILIATED WITH? ____________________________________________

________________________________________________________________________

32. DESCRIBEANYOFFICESYOUHAVEHELDINORGANIZATIONSLISTEDABOVE:

________________________________________________________________________

33. DO YOU KNOW ANYONE ON THIS JURY PANEL? ___________________________

________________________________________________________________________

34. HAVE YOU EVER SERVED ON A JURY BEFORE? [] YES [] NO

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HOW MANY TIMES? _______________

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 THE JURY SERVICE A POSITIVE OR NEGATIVE EXPERIENCE? __________

35. IF YOU HAVE EVER BEEN TO COURT FOR ANY OTHER REASON (EXCLUDING

TRAFFIC TICKETS AND DIVORCE), PLEASE EXPLAIN: ______________________

________________________________________________________________________

36. IF YOU HAVE RELATIVES OR CLOSE PERSONAL FRIENDS WHO ARE JUDGES,

ATTORNEYS OR COURT PERSONNEL, WHAT ARE THEIR NAMES AND

RELATIONSHIPS TO YOU? _______________________________________________

________________________________________________________________________

37. DESCRIBE ANY PROBLEMS (VISION, HEARING, OR OTHER MEDICAL

PROBLEMS) THAT MAY AFFECT YOUR JURY SERVICE? ____________________

________________________________________________________________________

38. IF YOU OR ANYONE CLOSE TO YOU HAS EVER MADE ANY TYPE OF CLAIM

FOR DA MAGES , EXPLAIN :

____________________________________________________

________________________________________________________________________

________________________________________________________________________

_________________________________________________________________________

39. IF A CLAIM FOR MONEY DAMAGES HAS EVER BEEN MADE AGAINST YOU OR

ANYONE CLOSE TO YOU, EXPLAIN THE CIRCUMSTANCES: _________________

________________________________________________________________________

________________________________________________________________________

40. IF YOU OR ANYONE CLOSE TO YOU HAS EVER SUED OR BEEN SUED IN ANY

TYPE OF LAWSUIT, EXPLAIN: ____________________________________________

________________________________________________________________________

________________________________________________________________________

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41. DO YOU FEEL THAT MONEY DAMAGES AWARDED IN LAWSUITS ARE (CHECK

ONE): [] EXCESSIVE [] OCCASIONALLY TOO LOW

[] OFTEN TOO LARGE [] OFTEN TOO LOW

[] ABOUT RIGHT [] OTHER (SPECIFY) _________________

____________________________________

_____________________________________

42. IF YOU HAVE ANY ETHICAL, RELIGIOUS, POLITICAL OR OTHER BELIEFS THAT

MAY PREVENT YOU FROM SERVING AS A JUROR, EXPLAIN: _______________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

43. IS THERE ANY REASON WHY YOU COULD NOT SERVE ON A JURY BETWEEN NOW AND JANUARY 31, 2006, IF YES, PLEASE EXPLAIN IN DETAIL:__________ ________________________________________________________________________

________________________________________________________________________

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