Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_13-cv-05203/USCOURTS-cand-3_13-cv-05203-3/pdf.json

Nature of Suit Code: 365
Nature of Suit: Personal Injury - Product Liability
Cause of Action: 28:1332 Diversity-Petition for Removal

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United States District Court

Northern District of California

UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF CALIFORNIA

ARTHUR R. YOST, et al.,

Plaintiffs,

v.

ROHM GMBH, et al.,

Defendants.

Case No. 13-cv-05203-JST 

COURT’S INTENDED JUROR 

QUESTIONNAIRE

In advance of the trial currently scheduled for January 11, 2016, the Court wishes to solicit 

counsel’s views regarding an appropriate written jury questionnaire. The Court intends to submit 

a written questionnaire to prospective jurors by mail in advance of the trial. Counsel may ask 

follow-up questions to responses in the questionnaire and may ask additional questions during voir 

dire. The Court intends to allow counsel to conduct at least some portion of voir dire, subject to 

time limits. 

The Court has attached a proposed form of questionnaire. The Court requests that the 

parties provide the Court with a list of names of persons who may testify at trial by November 9, 

2015, so that this information can be included in the form sent to prospective jurors. The Court 

can provide additional or amended information to prospective jurors on the day of trial. Parties’ 

comments, objections to the forms of question, or suggested modifications to the questionnaire 

may also be submitted by November 9, 2015. The Court will rule on any suggestions or 

objections without a hearing. 

IT IS SO ORDERED.

Dated: November 2, 2015

______________________________________

JON S. TIGAR

United States District Judge

Case 3:13-cv-05203-JST Document 52 Filed 11/02/15 Page 1 of 4
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United States District Court

Northern District of California

JUROR QUESTIONNAIRE - INSTRUCTIONS

The integrity of our legal system depends on the fairness and impartiality of jurors. This 

questionnaire has been prepared to assist the Court and the parties in this case to determine 

whether you may have had personal experiences related to, or prior knowledge concerning, the

issues to be decided by the jury. Please fill out this questionnaire completely in ink. Since we need

to make copies, do not write on the back of any page. If you need more room, continue at the

bottom or side of the page, or on the last page (noting question number). 

Please answer the questions honestly and completely. There are no right or wrong answers

to any question. This questionnaire is part of the trial record, but will not be available generally to

the public without an order of the Court. If you find that some of the questions call for sensitive 

personal information that you wish not to disclose here, please indicate that in your response. You

will be provided an opportunity to speak with the judge and/or the attorneys outside the presence

of other jurors. 

At the end of the questionnaire, you will be asked to sign the questionnaire and to declare 

under penalty of perjury that your answers are true and correct.

Thank you for your cooperation.

JUROR QUESTIONNAIRE

Please fill out this form as completely as possible and print clearly. Since we will make copies for 

the attorneys and the Court, do not write on the back of any page. 

1. Your name: 

2. Your age: 

3. The city where you live: 

How long you have lived there:

4. Your place of birth: 

5. Do you rent or own your own home? 

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United States District Court

Northern District of California

6. Your marital status: (circle one)

single married live with partner separated divorced widowed

7. What is your occupation, and how long have you worked in it? (If you are retired, please

describe your main occupation when you were working).

8. Who is (or was) your employer?

9. How long have you worked for this employer? 

10. Please list the occupations of any adults with whom you live.

11. If you have children, please list their ages and genders and, if they are employed, please 

give their occupations.

12. Please describe your educational background:

Highest grade completed: 

College and/or vocational schools you have attended:

Major areas of study:

13. Have you ever served on a jury before? ________ How many times?________

If yes: State/County Court _______ Federal Court _______

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United States District Court

Northern District of California

When? 

Was it a civil or criminal case? 

Did the jury(ies) reach a verdict? 

14. Attached is a list of the parties in this case, the law firms representing the parties, attorneys 

in this case, and persons who are potential witnesses in this case. Do you know, or think 

you know, any of the persons listed?

Yes:_____ No:_____

If so, make a check next to their name.

VERIFICATION

I, _____________________________, declare under penalty of perjury under the laws of the State 

(PRINT FULL NAME)

of California and the United States of America, 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

List of Parties, Potential Witnesses, and Other People Connected With This Case 

Case 3:13-cv-05203-JST Document 52 Filed 11/02/15 Page 4 of 4