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Juror Confidential Data Form

  1. 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.

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

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

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

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

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

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

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

  9. How much education have you completed? *

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

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

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

  13. Do you think marijuana should be legal? *

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

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

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

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

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

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

  20. 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?*

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

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

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

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

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

  26. COVID-19 Supplemental Questions

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

  28. 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

  29. Leave This Blank: