# COURT-MARTIAL MEMBER QUESTIONNAIRE

You have been nominated to serve as a member of a court-martial. Accordingly, this questionnaire is submitted to you under Rule for Courts-Martial 912, Manual for Courts- Martial. This questionnaire should be completed, signed and returned as soon as possible. Entries should be typed or printed.

**PRIVACY ACT STATEMENT**

**1.    AUTHORITY**: 10 U.S.C. §§ 825, 841

2. **PRINCIPAL PURPOSE:**The information solicited is intended principally for use in the administration of military justice.

3. **ROUTINE USES:**

a. To assist the court-martial convening authority in evaluating your qualifications for court-martial duty.

b. To assist counsel in the exercise of statutory rights to challenge members of court-martial and to assist the military judge in ruling on such challenges.	By requesting this information on a one-time basis before you actually serve as a member, repetitive questions and unnecessary delay can be avoided.

c. To assist reviewing authorities in resolving issues relating to your qualifications for court-martial duty.

4. **DISCLOSURE MANDATORY/VOLUNTARY, CONSEQUENCES OF REFUSAL TO DISCLOSE**: Disclosure is mandatory and failure to provide the information solicited may result in disciplinary action or criminal proceedings.

Page **1**of **8**

**COURT-MARTIAL MEMBER QUESTIONNAIRE**

PLEASE ATTACH YOUR CG MEMBER INFORMATION REPORT FROM DIRECT ACCESS. YOU MAY SKIP ANY QUESTION THAT CALLS FOR INFORMATION THAT IS ALREADY COMPLETELY AND CORRECTLY LISTED ON YOUR ATTACHED ESS.

1. Full Name (Last, First, Middle):

2. Rate/Rank/Designator: 

3. Date of Rank:

4. Branch of Service:

5. (For Officers Only) Source of Commission:

6. Place of Birth:

7. Marital Status:	Never Married	Married	Separated

Divorced in	Widow/Widower since 

8. If currently married: Spouse’s Occupation: 

Spouse’s Place of Work: 

Spouse’s Job Description: 

Years Spouse has been at Current Job: 

9. Contact Information:

Office Telephone: 

Cell Phone Number:

Email:

Page ******8******of **8**

10. Do you have children? ○Yes/○No. If “yes”, indicate the following:

11. Have you served in another armed force?	○Yes/○No Armed Force: 

Dates & Number of Years: 

Highest Rank Attained: 

12. Total Years of Active Duty: 

13. (For Officers Only) Are you prior enlisted? ○Yes/○No	Number of Years Enlisted: 

14. List any education, training, certifications, or C-Schools that are not reflected on your Employee Summary Sheet.  If any position descriptions are inaccurate on your ESS, please provide the

correct information here.

15. Have you taken any law courses (including civilian education such as law school, undergraduate work in criminal justice, or military schools such as legal officer training, law enforcement academies, or a Commander’s legal course)?

○Yes/○No, if “yes”, indicate the following:

16. Have you ever been assigned to investigate a matter outside of your primary duties? Examples include: Preliminary Inquiry Officer (command investigation of misconduct), AIM or Mishap investigation, or Preliminary Hearing Officer for a hearing under Article 32, UCMJ?

○Yes/○No, if “yes” indicate the following:

17. Have you ever been a Commanding Officer? ○Yes/○No (If no, skip to Question 19).

General Court-Martial (GCM): ○Yes/○No

18. Have you ever served as a Summary Court-Martial Officer?

○Yes/○No, if “yes”, indicate the following:

Number of times: 

Dates (year only): 

19. Have you ever imposed Non-Judicial Punishment (NJP) ○Yes/○No

Number of times: 

Dates (year only): 

20. Have you ever been appointed as a member of a General (GCM) or Special Court- Martial (SPCM)?

○Yes/○No, if “yes”, indicate the following:

21. Have you ever served on an Administrative Separation Board or on a Board of Inquiry?

○Yes/○No, if “yes”, indicate the following:

When did you serve? 

What was the charge or reason for separation? 

What did the board determine? 

22. Have you ever served as a juror in a civil or criminal civilian trial (state or federal)? ○Yes/○No , if “yes”, indicate the following:

When did you serve? 

What was the nature of the case? 

What did the jury determine? 

23. Have you ever appeared as a witness in military or civilian court?

○Yes/○No, if “yes”, indicate the following:

When did you appear? 

For which side did you appear? 

24. Have you had any specialized law enforcement training, civilian or military (either before or after entering the military service)? Examples include civilian police academy, courses at FLETC, MLEA, and Coast-Guard specific courses like boarding officer school.

○Yes/○No, if “yes,” describe:

25. Have you worked in any capacity as law enforcement? Examples include civilian police officer, reserve police officer, military police or shore patrol, boarding officer or team member, etc.

○Yes/○No, if “yes”, explain:

26. Are you taking any medications that might affect your ability to devote your undivided attention to the court-martial proceedings? ○Yes/○No

27. Have you or anyone close to you ever been arrested?

○Yes/○No, if “yes”, explain:

28. Have you or anyone else close to you ever been charged with a crime?

○Yes/○No, if “yes”, explain:

29. Have you ever had to call the police or have the police ever been called on you or anyone close to you? ○Yes/○No, if “yes”, explain:

30. Have you or anyone close to you ever been the victim of any crime? ○Yes/○No, if “yes”, indicate the following:

Person’s relationship to you: 

Incident: 

31. Have you or anyone close to you ever been involved in any of the following areas? If “yes”, explain who and briefly describe the job.

Crime       Prevention       (police       officer,       sheriff,       detective,       etc.) Medicine (nurse,                        doctor,                        pharmacist,                        etc.) Law (judge, attorney, etc.)

32. Please list any social, professional, civic, victim- advocacy, or civil-liberties organizations that you or your spouse are a member of:

33. Have you ever served as a victim advocate or received any training in the field of sexual assault or victim advocacy (e.g. Victim Advocate, SAVI, SARC, CIT)?

○Yes/○No if “yes”, when, what role or training, and what type of cases were involved:

34. Have you ever served as a member of a member of a Family Advocacy Program (FAP) board or committee? ○Yes/○No, if “yes”, when, what role, and what type of cases were involved:

35. Other than General Military Training (e.g. Learning Portal), have you ever served or received any training in the field of alcohol and substance abuse? For example, training to be a civilian bartender, collateral duty drug or alcohol program coordinator training, or university psychology classes dealing with substance abuse. ○Yes/○No, if “yes”, when and please describe:

36. Please describe the sexual assault awareness training, education, counseling, or indoctrination you have been exposed to within the last 24 months (written communications, “all hands,” social media, informal discussions, viewing posters or videos, etc.)

37. Have you, or someone close to you, ever delivered sexual assault awareness or prevention training, education, indoctrination, counseling, etc. – or worked as a counselor, support person, advocate, medical provider, or in some other capacity in a case involving sexual assault? If yes, describe.

38. Have you ever served in any capacity in a command or service sponsored urinalysis program? ○Yes/○No, if “yes”, when and please describe:

39. If you were sitting at the defense table as the accused, would you be satisfied to have your guilt or innocence and sentence determined by a court member who was in your present state of mind? ○Yes/○No

40. Is there anything in your background or experience that might affect your ability to be a fair and impartial decision-maker? ○Yes/○No

Signature	Date

# image4.png

# image1.png

# image2.png

# image3.png