JUROR #________ 

UNITED STATES DISTRICT COURT 

DISTRICT OF ARIZONA 

In Re Bard IVC Filters Products Liability 

Litigation 

No. MD-15-02641-PHX-DGC 

SHERR-UNA BOOKER, an individual, 

Plaintiff, 

v. 

C.R. BARD, INC., a New Jersey 

corporation and BARD PERIPHERAL 

VASCULAR, an Arizona corporation, 

Defendants. 

CONFIDENTIAL JUROR 

QUESTIONNAIRE 

Only the Court and the attorneys will use the information that you give in response to this 

questionnaire. Your responses to this questionnaire will be kept confidential and all parties will be under 

orders to maintain the confidentiality of any information they learn in the course of reviewing these 

questionnaires. 

Please answer each question below as completely and as accurately as you reasonably can. 

PLEASE COMPLETE YOUR ANSWERS IN PEN and print all answers legibly. If there is not enough 

space for you to complete an answer, please write the number of the question and complete your answer 

in the blanks provided on the last page. Please do not write on the back of any page. 

If there is a question that you do not want to answer because of privacy concerns, then write in the 

blank by that question the word “privacy.” You may need to visit with the Judge and the attorneys out of 

the presence of the other potential jurors concerning that question. 

If you simply cannot understand a question, then write in the blank by that question the words “do 

not understand.” 

You are expected to sign your questionnaire, and your answers will have the effect of a statement 

given to the Court under oath. What is needed is your very best, honest effort to answer the questions 

contained in this questionnaire. Do not consult with any other person in answering the questions. After 

Case 2:15-md-02641-DGC Document 9379-1 Filed 12/15/17 Page 1 of 14
completion of the questions, do not discuss this case with anyone, because you are a potential juror. Return 

the completed questionnaire to the Court. Brief but clear answers will allow us to review your background 

before you report to the courtroom and should help speed the selection process. Thank you for your 

cooperation. 

The sole purpose of the questionnaire is to encourage your full expression and candor so that the 

parties will have a meaningful opportunity to select a fair and impartial jury to try the issues of the case. 

Your full cooperation is of vital importance. Thank you for your assistance. 

 

 Honorable 

 United States District Judge

Case 2:15-md-02641-DGC Document 9379-1 Filed 12/15/17 Page 2 of 14
1. Full Name (first) (middle) (last) : _________________________________ Age: ______ 

2. Do you have any limitations in your ability to read or understand oral or written testimony 

in English?  YES  NO 

If yes, please explain: ______________________________________________________ 

3. Please check one:  MALE  FEMALE 

4. Place of birth: ____________________________________________________________ 

5. What is your racial/ethnic background? 

 White/Caucasian  Black/African-American 

 Hispanic/Latino  American Indian or Native American 

 Asian or South Asian  Other (please specify) 

6. In what city and county do you currently live? __________________________________ 

7. Length of time at current address: ____________________________________________ 

a) If you have lived less than five years at your current address, indicate other places 

you have lived. ________________________________________________________ 

_____________________________________________________________________ 

8. Your current marital status: 

 Married, ____ years  Partnered, ___ years 

 Never married  Separated, ___ years 

 Divorced, ____ years  Widowed, ___ years 

9. Your highest level of education completed: 

 Less than high school 

 High school graduate 

 Some college: (Major: _________________) 

 Technical or vocational school: (Type: ___________________) 

 College graduate: (Major: _________________) 

 Post graduate degree: (Major: _________________) 

10. Educational background of your spouse or significant other, including any degrees or 

certificates earned: ________________________________________________________ 

________________________________________________________________________ 

11. Your current employment status (check all that apply): 

 Employed full-time  Employed part-time 

 Business owner  Homemaker 

 Self-employed  Unemployed 

 Retired in ___ (year)  Full-time student 

 Disabled, do not work  Work more than one job 

 Laid off  Do not work outside the home 

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12. Please answer for your current job or, if unemployed, for your last job: 

a) Employer: ____________________________________________________________ 

b) How long: ____________________________________________________________ 

c) Position and job duties: __________________________________________________ 

13. Do you currently supervise others at work or have you in prior jobs? 

 YES (How many? ______) 

 NO 

If yes, please describe: _____________________________________________________ 

________________________________________________________________________ 

14. Please list your previous employers and jobs for the past 10 years: 

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________ 

15. Have you ever owned and/or managed your own business?  YES  NO 

16. Spouse or significant other’s name, occupation, job title and employer (If he/she is 

unemployed or retired, please list last job.): ____________________________________ 

________________________________________________________________________ 

17. List any hobbies and special interests that you have: ___________________________ 

________________________________________________________________________ 

18. Do you do any volunteer work (professional, community, social clubs or organizations)? 

 YES  NO. 

If yes, please describe: ____________________________________________________ 

________________________________________________________________________ 

19. Do you serve in any leadership role at work or in any professional or community groups 

or organizations?  YES  NO 

If yes, please describe: ____________________________________________________ 

20. Which of the following words or phrases would you use to describe yourself? Circle all 

that apply. 

Analytical Assertive Athletic Careful Cautious 

Compassionate Smart Creative Decisive Detailed 

Determined Emotional Frugal Generous Snap-Decision 

Skeptical Leader Logical Quiet Sensitive 

Shy Open-Minded Opinionated Outspoken Religious 

Follower Team Player 

21. List the names, ages, occupations of your children, step-children, and grandchildren: 

 

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22. If employed, list children’s occupations and employers: 

_______________________________________________________________________ 

_______________________________________________________________________ 

_______________________________________________________________________ 

23. Regarding your residence, check all that apply. 

 House, townhome  Rent 

 Condominium  Own 

 Apartment  Live with others and do not pay rent 

24. Prior military service? If so, please specify branch, rank, date, years served, and type of 

discharge: 

_______________________________________________________________________ 

25. Are you or anyone in your family in any of the professions below either now or in the past? 

Circle all that apply. 

Accounting Business Finance Law/Legal Government 

Engineering Chemistry Insurance Psychology Social Services 

Medicine/ 

 Healthcare 

Product 

 Development 

FDA Advertising R&D 

If yes, please state the relationship and the type of legal profession: __________________ 

________________________________________________________________________ 

26. What are your main source(s) of news? 

 Television (Which news channel(s)? __________________________________ ) 

 Radio (Which news station(s)? _______________________________________ ) 

 Newspaper (Which newspaper(s)? ____________________________________ ) 

 Magazine (Which magazine(s)? ______________________________________ ) 

 Internet 

 Family/Friends 

 I don’t follow the news 

27. Do you or your spouse or partner have bumper stickers on your car?  YES  NO 

If yes, what do they say? ____________________________________________________ 

28. Do you regularly use social networking sites on the internet (e.g., Facebook, Twitter, etc.)? 

 YES  NO 

29. Do you currently serve as a caretaker for someone who is ill or disabled?  YES  NO 

If yes, please explain: ______________________________________________________ 

________________________________________________________________________ 

30. Please list 3 people you admire the most: 

a. _______________________________ 

b. _______________________________ 

c. _______________________________ 

Case 2:15-md-02641-DGC Document 9379-1 Filed 12/15/17 Page 5 of 14
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31. Please list 3 people you admire the least: 

a. _______________________________ 

b. _______________________________ 

c. _______________________________ 

32. Have you ever served on a jury before?  YES  NO 

a. How many times? _______ 

b. Where did you serve? ___________________________________________________ 

c. What types of case(s)? __________________________________________________ 

d. Were you ever the jury foreperson? ________________________________________ 

e. Was your jury service a positive or negative experience? ________________________ 

33. Have you, your relatives or anyone close to you ever: 

Yourself Someone 

Close 

  a. Sued someone else 

  b. Been sued by someone else 

  c. Been involved in a lawsuit of any kind either as a plaintiff, 

or defendant, or a witness 

  d. Suffered from any type of permanent injury, disease or 

disability 

  e. Been unable to work due to a permanent injury, disease or 

disability 

  f. Been involved in an accident that resulted in loss or injury 

  g. Ever filed a legal claim or complaint of any sort against an 

individual or entity 

  h. Made a personal injury claim or filed for worker's 

compensation 

 If you answered yes to any of the above, please explain: ___________________________ 

________________________________________________________________________ 

________________________________________________________________________ 

________________________________________________________________________ 

34. For the following, please indicate how you feel about them. Use a scale from 1 to 7, where 

1 is “feel extremely negative” and 7 is “feel extremely positive” and you may use any 

number in between as well. 

Personal injury lawyers 

Extremely Negative 1 2 3 4 5 6 7 Extremely Positive 

Medical Device Manufacturers 

Extremely Negative 1 2 3 4 5 6 7 Extremely Positive 

Corporations 

Extremely Negative 1 2 3 4 5 6 7 Extremely Positive 

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35. This case involves Inferior Vena Cava (“IVC”) filters that are implanted into a patient’s 

vein to prevent blood clots from reaching the lungs or heart. Is there anything about this 

subject matter that causes you to believe that you could not consider the evidence fairly, 

impartially, and according to the jury’s instructions?  YES  NO 

If yes, please explain: ______________________________________________________ 

________________________________________________________________________ 

________________________________________________________________________

36. Have you read or heard anything about lawsuits involving any medical devices, including 

IVC filters?  YES  NO 

If yes, please explain what you have read or heard: _______________________________ 

________________________________________________________________________ 

________________________________________________________________________ 

________________________________________________________________________ 

37. Have you read or heard anything (in the media, from family or friends) about C. R. Bard 

or Bard Peripheral Vascular, medical device manufacturers?  YES  NO 

If yes, please explain what you have read or heard and please identify any media report 

you can recall: ___________________________________________________________ 

________________________________________________________________________ 

________________________________________________________________________ 

38. Have you read or heard anything (in the media, from family or friends) about IVC filters? 

 YES  NO 

If yes, please explain what you have heard or read: ______________________________ 

________________________________________________________________________ 

________________________________________________________________________ 

________________________________________________________________________ 

39. If you have heard or read something about lawsuits involving any medical devices, 

including IVC filters, would what you have heard or read make it difficult for you to serve 

as a fair and impartial juror in this case? If yes, please explain: 

________________________________________________________________________ 

________________________________________________________________________ 

________________________________________________________________________ 

40. Is there any anything else that you think might affect your ability to be fair and impartial 

to both sides of a product defect case against a medical device manufacturer? 

 YES  NO 

If yes, please explain: ______________________________________________________ 

________________________________________________________________________ 

________________________________________________________________________ 

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41. Have you, your relatives or anyone close to you ever worked for C. R. Bard or Bard 

Peripheral Vascular?  YES  NO 

If yes, please describe who, the job title and dates of employment: ___________________ 

________________________________________________________________________ 

________________________________________________________________________ 

42. Have you, your relatives or anyone close to you ever worked for a company that 

manufactured or sold IVC filters?  YES  NO 

If yes, please describe who, the name of the company, the job title and dates of 

employment: ____________________________________________________________ 

________________________________________________________________________ 

________________________________________________________________________ 

43. Have you, your relatives or anyone close to you ever worked for a medical device 

company?  YES  NO 

If yes, please identify the person(s), the work performed and the dates of employment: 

________________________________________________________________________ 

________________________________________________________________________ 

44. Have you, your relatives or anyone close to you ever worked for a health care facility (e.g., 

hospital, physician’s office, critical care center or medical clinic)?  YES  NO 

If yes, please identify the person(s), the work performed and the dates of employment: 

________________________________________________________________________ 

________________________________________________________________________ 

45. Do you have any strong feelings positive or negative about people that file lawsuits? If 

yes, please describe: _______________________________________________________ 

________________________________________________________________________ 

________________________________________________________________________ 

46. Have you, your relatives or anyone close to you ever been diagnosed with any of the 

following? Check all that apply. 

 Blood Clots  Pulmonary Embolism (PE) 

 Deep Venous Thrombosis (DVT) 

If you have checked any of the above, please identify the person(s), and describe the 

complication and outcome: __________________________________________________ 

________________________________________________________________________ 

________________________________________________________________________ 

Case 2:15-md-02641-DGC Document 9379-1 Filed 12/15/17 Page 8 of 14
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47. Have you, your relatives or anyone close to you ever been prescribed or taken anticoagulation medication (“blood thinners”), such as Coumadin, Warfarin, Xarelto or 

Lovenox?  YES  NO 

If yes, please identify the person(s), the name of the medication(s) and outcome: 

________________________________________________________________________

_______________________________________________________________________ 

48. Have you, your relatives or anyone you personally know ever had an IVC filter or medical 

device implanted?  YES  NO 

If yes please identify: 

The person(s): ______________________________________________________ 

Type of medical device: ______________________________________________ 

Manufacturer of medical device: _______________________________________ 

Any complications experienced with device: ______________________________ 

49. Do you know anyone who had a negative experience or suffered injuries from an IVC 

filter? 

 YES  NO 

If yes, please explain: ______________________________________________________ 

________________________________________________________________________ 

________________________________________________________________________ 

________________________________________________________________________ 

50. Do you know anyone who had a negative experience or suffered injuries from any other 

medical device or prescription drug?  YES  NO 

If yes, please explain: ______________________________________________________ 

________________________________________________________________________ 

________________________________________________________________________ 

51. If you, or a family member or someone close to you, had a negative experience with any 

type of medical device or prescription drug, would that experience make it difficult for you 

to serve as a fair and impartial juror in this case? If yes, please explain: ______________ 

________________________________________________________________________ 

________________________________________________________________________ 

52. Do you or someone in your immediate family have experience in the following? (Check 

all that apply): 

 Drug or medical device company  Product design or testing 

 Medicine/medical field  Quality Assurance/Quality Control 

 State/federal regulatory agencies, e.g. FDA  Health Hazard Evaluations (HHE) 

 Law/legal system  Root Cause Analysis 

 Insurance industry  510k 

 Education/teaching  PMA 

 Sales or marketing  MAUDE 

 Engineering  Medical Device Reports (MDR) 

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If you have checked any of the above, please explain: _____________________________ 

________________________________________________________________________ 

________________________________________________________________________ 

________________________________________________________________________ 

________________________________________________________________________ 

53. Compared to five years ago, do you have an unusual financial hardship or other serious 

problem that would prevent you from serving as a juror in this case?  YES  NO 

If yes, briefly explain the hardship: ____________________________________________ 

________________________________________________________________________ 

54. From what you have heard or read, do you think in recent years, the number of injury 

lawsuits filed has generally been: 

 Too high 

 About right 

 Too low 

55. From what you have heard or read, do you think money damages from recent lawsuits have 

generally been: 

 Too high 

 About right 

 Too low 

56. Do you support legislative reforms to place caps or limits on the amount of money juries 

can award?  YES  NO 

If yes, please explain: ______________________________________________________ 

________________________________________________________________________ 

57. If you are chosen to be a juror, and while jury selection is in process, you are not permitted 

to read or listen to any media or Internet coverage of this case and related subjects while 

the case is pending. Will you be able to follow these restrictions in light of the fact that this 

trial will be lengthy?  YES  NO 

If no, please explain: _______________________________________________________ 

________________________________________________________________________ 

58. If you are chosen to be a juror, and while jury selection is in process, the Court will instruct 

you that you will not be able to blog, tweet, post on Facebook or other social networks, talk 

about, or otherwise communicate anything about this case while the case is pending. Is 

there any reason why you cannot follow this instruction?  YES  NO 

If yes, please explain: ______________________________________________________ 

Case 2:15-md-02641-DGC Document 9379-1 Filed 12/15/17 Page 10 of 14
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59. Do you have any ethical, religious, moral, political, philosophical or other beliefs that 

would prevent you from applying the law to the evidence of the case?  YES  NO 

If yes, please explain: ______________________________________________________ 

________________________________________________________________________ 

60. Do you know of any reason you could not be a fair, impartial, unbiased juror in this lawsuit? 

 YES  NO 

If yes, please explain: ______________________________________________________ 

________________________________________________________________________ 

61. Do you have any serious medical condition or health problem that might make it difficult 

or affect your ability to serve as a juror in this case?  YES  NO 

If yes, please explain: ______________________________________________________ 

62. Is there any reason you cannot serve on this jury if the trial lasts three weeks? 

 YES  NO 

If yes, please explain: ______________________________________________________ 

________________________________________________________________________ 

63. The attorneys may need to ask you follow-up questions. Are there any questions you would 

prefer to discuss in private?  YES  NO 

If yes, please indicate the question numbers here: ________________________________ 

64. Is there anything else that you would like the Court or the attorneys to know? 

 YES  NO 

If yes, please explain: 

 

65. On the last page of this Questionnaire, there is list of people who may be involved in the 

case. Please circle those you know, have heard, or worked with for/with. 

SPACE FOR ADDITIONAL RESPONSES. Please include the number of the question for 

which you are supplying additional information. 

______________________________________________________________________________

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Case 2:15-md-02641-DGC Document 9379-1 Filed 12/15/17 Page 11 of 14
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Case 2:15-md-02641-DGC Document 9379-1 Filed 12/15/17 Page 12 of 14
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AFFIRMATION 

I, _______________________ hereby declare under penalty of perjury that the foregoing 

answers set forth in this Jury Questionnaire are true and correct to the best of my knowledge 

and belief. I have not discussed my answers with others or received assistance in completing 

the questionnaire. I have answered all of the above questions in this Jury Questionnaire 

myself. 

Executed on this day of March, 2018. 

 _____________________________________________ 

 Signature 

 

Case 2:15-md-02641-DGC Document 9379-1 Filed 12/15/17 Page 13 of 14
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Below is a list of people who may be involved in the case. Please circle those you know, have 

heard, or worked with for/with. 

 

Case 2:15-md-02641-DGC Document 9379-1 Filed 12/15/17 Page 14 of 14