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Juror Confidential Data Form

2. You have been selected as a prospective juror for the Courts of Jefferson County for January-December 2021. If chosen, you will be notified by separate summons as to the day and time you must appear. Currently, trials are being conducted at the Venture Out Business Center, 975 Industrial Drive, Madison, Indiana. The following form is designed to assist the Court and the lawyers. It will not be used for any other purpose. This questionnaire is confidential.

4. Name*

5. Juror #*

6. Age*

8. Address*

10. City*

11. State*

12. Zip Code*

16. If you have lived at any other address in the last five years, please list each address:

18. If you work outside the home, what is your occupation and who is your current employer?

20. If you are married or if you live with a companion, what is her or his name and occupation, if any?

22. With respect to other members of your household, if any, please state their names, ages, occupations, and employers, if applicable:

24. Have you or anyone close to you ever been the victim of a crime?*

    1. Yes
    2. No

25. If yes, please explain:

27. Are you or any member of your family related to, or a close friend of any law enforcement officer?*

    1. Yes
    2. No

28. If yes, please explain:

32. Have you ever been called for jury service before? *

    1. Yes, but NOT SELECTED as a juror
    2. Yes, and SELECTED as a juror
    3. No

33. If you were selected as a juror, please specify the type of case.

    1. Civil
    2. Criminal
    3. Unsure

35. What was the outcome of the case?

37. What concerns you most about the jury system?

41. Have you ever appeared as a witness in a court?*

    1. Yes
    2. No

42. If yes, please specify the type of case.

    1. Civil
    2. Criminal
    3. Unsure

44. If you appeared as a witness, for whom did you testify?

46. What concerns you most about that court proceeding, if applicable?

50. Have you or any member of your family ever been involved in a lawsuit?*

    1. Yes

    1. No

52. If yes, please describe briefly the type of lawsuit and the outcome of the proceeding:

56. How much education have you completed? *

    1. Grade School
    2. High School
    3. College

    1. Graduate School
    2. Vocational School or Specialized Training

57. What did you study or type of training did you have?

61. Have you or any members of your immediate family served in the military?*

    1. Yes
    2. No

62. If so, when and what branch?

66. How do you keep up with the news? *

    TV, Newspapers/Magazines, Social Media, Friends or Don't keep up with the news. Please specify which newspaper or website.

68. How often do you read the newspaper or look at social media?*

    1. Daily
    2. Weekly
    3. Monthly

    1. Once in a while
    2. Never

70. Which books, newspapers or magazines, or social media sites if any, have you read or viewed in the last three months?

72. Which television programs, if any, do you regularly watch?

74. How do you spend your free time?

76. Please list any organizations or associations to which you belong, such as PTA, social clubs, political organizations, etc.:

78. Please list any organizations or associations to which your spouse / partner, if any, belongs:

82. Do you think marijuana should be legal? *

    1. Yes
    2. No

    1. Undecided
    2. Choose not to answer

83. Additional comments, if any:

85. Do you, on occasion, drink socially?*

    1. Yes
    2. No
    3. Choose not to answer

86. If not, are you opposed to social drinking?

    1. Yes
    2. No

88. Do you have any disabilities or health related problems which would make it difficult for you to serve as a juror? *

    1. Yes
    2. No

89. If yes, please explain:

91. Is there any information which you would like to provide to the Court that you believe is relevant to your ability to serve as a juror in this case?

93. Do you or have you suffered from a mental illness?*

    1. Yes
    2. No

94. If you answered yes, please explain:

96. Do you have any pressing matters of a family or personal nature which would make it difficult or impossible for you to serve as a juror?

98. Do you prefer to be alone or with others?*

    1. With Others
    2. Alone
    3. Unsure

99. Do you consider yourself as a leader or a follower?*

    1. Leader
    2. Follower
    3. Unsure

103. Do you have a family member or close friend who works in the legal system as a judge, lawyer, court reporter, paralegal, legal secretary or law enforcement officer?*

     1. Yes
     2. No

104. If you answered yes, please explain:

106. Are you or do you have a family member or a close friend who is a member of the clergy?*

     1. Yes
     2. No

107. If you answered yes, please explain:

109. Have you, a family member or close friend ever been charged with a crime?*

     1. Yes
     2. No

110. If you answered yes, please explain:

112. What do you think are the three biggest problems in your community?

     Please list answers using 1), 2), 3)

114. How do you feel about rules?

116. Have you or anyone close to you been convicted of a felony?*

     1. Yes
     2. No

117. If you answered yes, please explain:

119. Are you currently on probation or serving a sentence of house arrest, work release or under suspended sentence?*

     1. Yes
     2. No

120. If you answered yes, please explain:

124. COVID-19 Supplemental Questions

126. Have you experienced any recent illnesses?

128. Have you traveled anywhere outside the State of Indiana? If so, please describe:

130. Have you traveled on a commercial flight since January 1, 2020? If so, please describe:

132. Has anyone in your immediate family, social, or work circles tested positive for COVID-19? If so, please describe those circumstances in detail, including the date of the test.

134. Have you been contacted by anyone advising you that they have tested positive for COVID-19? If so, please describe in detail those circumstances.

136. Have you been tested for COVID-19? If so, when did that occur and what were the results?

138. Have you experienced a temperature above 100 in the last 30 days?

     1. Yes
     2. No

140. Within the last 14 days, have you experiences any of the following, that you cannot attribute to another health condition:

     Please check all that apply

     1. New cough
     2. Shortness of breath
     3. Sore throat
     4. Muscle aches

     1. Loss of smell or taste
     2. Chills
     3. Nausea, Vomiting or Diarrhea
     4. None
142. Is there any reason why are at a higher risk of contracting COVID-19 or experiencing complications from COVID-19? If so, please provide a brief explanation:

Leave This Blank:


143. Submit

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