COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : JUROR QUESTIONNAIRE : Calendar No. FOR CIVIL CASES : Index No. JUDICIAL SUBPOENA Plaintiff(s) Code of Civil Procedure Section 205(c)-(d) -against: : Sec. 1. Statutory Authority : This Juror Questionnaire has been drafted under the authority of Code of Civil Procedure Defendant(s) section 205(c)-(d) and is intended to expedite jury selection. It is not intended to alter : . . . . . . . . or .rules. governing. the .authority .of. the .court. or .the role of counsel during voir dire. .. .... ......... ... ........ . ... .... .. . statutes Sec. 2. Use Notes for Courts THE PEOPLE A. General OF THE STATE OF NEW YORK This Juror Questionnaire is intended for use in the court's discretion in appropriate civil TO cases. Its use in cases of brief duration may not be appropriate. Particular kinds of cases may require that this questionnaire be altered or augmented. The Personal Injury Supplement is intended to be used along with the General Questions in personal injury actions. Judges, in their own discretion, must determine what additional kinds of inquiry are GREETINGS: appropriate in any given case. B. Pre–VoirCOMMAND YOU, that all business and excuses being laid aside, you and each of you attend before WE Dire Conference The court should confer with counsel about the dire before a jury panel is called. At this , the Honorable at voir Court conference, the court may establish (1) guidelines for the use of the Juror Questionnaire, (2) located at County of any supplemental questionsday of propounded to the panel o'clock in the to be by questionnaire, (3) and at any recessed in room , on the , 20 , at noon, the extent of or adjourned oral testify of the panel, and (4) the extent on the part of the the court's date, toinquiryand give evidence as a witness in this actionof oral questioning by counsel. Proposed supplemental questions drafted by counsel should be filed and served at least three court days before the pre–voir dire conference. Arrangements for duplication of completed questionnaires with this subpoena is punishable as parties should share the cost liable to Your failure to comply should be confirmed. The a contempt of court and will make you of duplication.whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a the party on C. Introduction of Questionnaire to Prospective Jurors result of your failure to comply. It is suggested that the Juror Questionnaire be used after the court has given its customary introductory remarks and any additional instructions that the court deems appropriate. The Witness, Honorable , one of the Justices of the court in Court also may wish to tell the of County, day panel members that a questionnaire will be used, to , 20 encourage complete answers, and to remind them that their answers will be given under penalty of perjury. In introducing the questionnaire, the court should instruct prospective jurors how to proceed if they have difficulty reading or filling out the form. (Attorney must sign above and type name below) The court could direct that the Juror Questionnaire be given to prospective jurors by the jury commissioner in the jury assembly room. However, this procedure ordinarily will mean that jurors are not given complete instructions about the type of case they will hear or the identity Attorney(s) for of participants and witnesses. In addition, jurors who fill out the form before appearing in the trial court may not clearly understand that their answers are given under penalty of perjury. For these reasons, and to avoid the need to have jurors fill out supplemental questionnaires once they have been sent to the trial court, it is strongly recommended that the Juror Office and P.O. Address Questionnaire be used in the trial court setting. Form Approved by the Judicial Council of California MC-001 [Effective January 1, 2004] Optional Form Telephone No.: Facsimile No.: E-Mail Address: JUROR QUESTIONNAIRE FOR CIVIL CASES/Code of Civil Procedure section 205(c)-(d) Mobile Tel. No.: A American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. JUROR QUESTIONNAIRE : Calendar No. FOR CIVIL CASES Plaintiff(s) -againstIntroduction : JUDICIAL SUBPOENA : and Instructions : Thank you for coming to court as a potential juror. Before the case can start, a jury must be selected. The judge and the people involved in the case need to : know something about you in order to select jurors who can be fair to both sides. Defendant(s) : ...................................................... Everyone has attitudes and opinions that are shaped by their life experiences. Sometimes these experiences can make it difficult to look at a certain issue in an unbiased and unemotional way. As a juror, you must return a verdict based THE PEOPLE OF THE STATE OF NEWproved in court, not on emotion or on other views on the law and on the facts YORK not supported by the evidence. The judge will give you instructions on the law TO and on how you should go about deciding the case. You must listen to and follow the judge's instructions. The questions on this form are designed to help the court and the lawyers GREETINGS:something about your background and your views on issues that may be learn related to this case. The questions are asked not to invade your privacy, but to WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before make sure that you can be a fair and impartial juror. Court is any reason why If there , the Honorable at the you might not be ablelocated at both sides a fair trial in this case, it is important to give County of in roomthat you say so. , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the The judge has decided to use this form to save time and to give you a chance to tell the court and the lawyers about yourself. In portions of this form, you will see the punishable as a contempt of court and will make you liable to Your failure to comply with this subpoena is term "significant personal relationship." That term means a former was issued for a maximum penalty partner, or anyone the party on whose behalf this subpoena spouse, domestic partner, lifeof $50 and all damages sustained as a result ofwith whomtoyou have an influential or intimate relationship that you would your failure comply. characterize as important. Witness, Honorable , one of the Justices of the do not talk Court inIf there is anything you day of want to , 20 about in open court, please circle County, the question number. After you have finished the questionnaire, let the clerk know that you have circled one or more question numbers. (Attorney must sign above and type Do not write on the back of any page. Use an additional sheet of paper.name below) If you are called to the jury box, your answers to this questionnaire become a matter of public record, just as if you had answered the questions aloud in the Attorney(s) for courtroom. If you have trouble reading, understanding, or filling out this form, please let the court clerk know. Office and P.O. Address PLEASE REMEMBER THAT YOU ARE ANSWERING THESE QUESTIONS UNDER PENALTY OF PERJURY. YOUR ANSWERS MUST BE TRUE AND Telephone No.: COMPLETE. THANK YOU FOR YOUR HELP IN SELECTING A FAIR JURY. Form Approved by the Judicial Council of California MC-001 [Effective January 1, 2004] Optional Form Facsimile No.: E-Mail Address: JUROR QUESTIONNAIRE FOR CIVIL CASES/introduction and Instructions Mobile Tel. No.: B American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : JUROR QUESTIONNAIRE : Calendar No. FOR CIVIL CASES : Index No. JUDICIAL SUBPOENA Plaintiff(s) : General Questions -against- PLEASE PRINT ALL ANSWERS LEGIBLY : : FULL NAME: Defendant(s) : ...................................................... 1.1 THEDATE AND OF THE STATE OF NEW YORK PEOPLE PLACE OF BIRTH: TO AREA, NEIGHBORHOOD, OR COMMUNITY IN THIS COUNTY WHERE YOU CURRENTLY LIVE 1.2 (DO NOT GIVE YOUR ADDRESS): HOUSE APARTMENT OWN RENT GREETINGS: 1.3 AREA, NEIGHBORHOOD, OR COMMUNITY WHERE YOU HAVE LIVED IN THE PAST 10 YEARS (AND DATES): WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the 1.4 WHAT IS THE HIGHEST LEVEL OF EDUCATION YOU COMPLETED? GRADE SCHOOL OR LESS SOME COLLEGE (MAJOR): SOME HIGH to comply Your failure SCHOOL with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for aCOLLEGE GRADUATE $50 and all damages sustained as a maximum penalty of HIGH SCHOOL GRADUATE result of your failure to comply. (MAJOR): OTHER (PLEASE EXPLAIN): Witness, Honorable Court in County, POSTGRADUATE STUDY day of (MAJOR): , one of the Justices of the , 20 TECHNICAL, VOCATIONAL, OR BUSINESS SCHOOL (MAJOR): 1.5 (Attorney must sign above and type name below) IF YOU PLAN TO ATTEND OR ARE CURRENTLY ATTENDING SCHOOL, DESCRIBE: Attorney(s) for 1.6 IF YOU HAVE TAKEN ANY COURSES OR HAD ANY TRAINING IN MEDICINE OR OTHER HEALTH CARE FIELD, DESCRIBE: Office and P.O. Address Form Approved by the Judicial Council of California MC-001 [Effective January 1, 2004] Optional Form Telephone No.: Facsimile No.: E-Mail Address: JUROR QUESTIONNAIRE FOR CIVIL CASES/General Questions 1 Mobile Tel. No.: C-1 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. 1.7 IF YOU HAVE TAKEN ANY COURSES OR HAD ANY TRAINING IN LAW OR A RELATED SUBJECT, DESCRIBE: : Plaintiff(s) 1.8 Calendar No. : JUDICIAL SUBPOENA -against: EDUCATIONAL BACKGROUND OF ANY OTHER ADULT WHO LIVES IN YOUR HOME, INCLUDING ANY DEGREES OR CERTIFICATES EARNED: : : Defendant(s) YOUR PRESENT EMPLOYMENT STATUS (CHECK ALL THAT APPLY): : . . . . . . . .EMPLOYED FULL-TIME. . . . . . . . . . . . RETIRED. . . . . . . . . . UNEMPLOYED, LOOKING FOR WORK ................. ....... 1.9 EMPLOYED PART-TIME STUDENT UNEMPLOYED, NOT LOOKING FOR WORK HOMEMAKER THE PEOPLE OF THE STATE OF NEW YORK 1.10 YOUR CURRENT OR MOST RECENT OCCUPATION: TO 1.11 NAME OF YOUR CURRENT OR MOST RECENT EMPLOYER OR, IF A STUDENT, YOUR SCHOOL: GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable YOUR SPECIFIC DUTIES AND RESPONSIBILITIES ON THE JOB? at the Court 1.12 WHAT ARE located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the 1.13 DOES YOUR JOB INVOLVE SUPERVISING OTHER PEOPLE? NO YES IF YES, APPROXIMATELY HOW MANY? Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to YES NO the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. 1.15 ARE YOU INVOLVED IN EVALUATING THE JOB PERFORMANCE OF OTHER EMPLOYEES? YES NO 1.14 ARE YOU INVOLVED IN THE HIRING OR FIRING OF OTHER EMPLOYEES? 1.16 ALL OTHER EMPLOYMENT YOU HAVE HAD (AND FOR HOW LONG): Witness, Honorable Court in County, day of , one of the Justices of the , 20 (Attorney must sign above and type name below) 1.17 ALL FULL-TIME EMPLOYMENT OF YOUR SPOUSE OR ANY PERSON WITH WHOM YOU HAVE A SIGNIFICANT PERSONAL RELATIONSHIP (AND FOR HOW LONG): Attorney(s) for Office and P.O. Address 1.18 WHAT ARE/WERE THE OCCUPATIONS OF YOUR PARENTS? (IF RETIRED, WHAT DID THEY DO BEFORE?) MOTHER: FATHER: Form Approved by the Judicial Council of California MC-001 [Effective January 1, 2004] Optional Form Telephone No.: Facsimile No.: E-Mail Address: JUROR QUESTIONNAIRE FOR CIVIL CASES/General Questions 2 Mobile Tel. No.: C-2 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : 1.19 Index NOT IF YOU HAVE CHILDREN, PLEASE LIST (INCLUDING ANY CHILDREN WHO DONo. CURRENTLY LIVE WITH YOU): SEX AGE DOES CHILD LIVE WITH YOU? : Calendar No. : JUDICIAL SUBPOENA EDUCATION Plaintiff(s) -against- OCCUPATION : : 1.20 IF YOU OR YOUR CURRENT SPOUSE OR PERSON WITH WHOM YOU HAVE A SIGNIFICANT PERSONAL RELATIONSHIP HAS EVER SERVED IN THE MILITARY, PLEASE LIST FOR EACH THE BRANCH OF SERVICE : AND DATES OF SERVICE: Defendant(s) : ...................................................... 1.21 WHAT SOCIAL, CIVIC, PROFESSIONAL, TRADE, OR OTHER ORGANIZATIONS ARE YOU AFFILIATED WITH? THE PEOPLE OF THE STATE OF NEW YORK TO 1.22 DESCRIBE ANY OFFICES YOU HAVE HELD IN ORGANIZATIONS LISTED ABOVE: GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court 1.23 DO YOU KNOW ANYONE ON THIS JURY PANEL? located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to ON HOW MANY CASES HAVE YOU SERVED ON A JURY? the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure toYOU SERVE ON A JURY? WHERE DID comply. 1.24 WHAT KINDS OF CASES DID YOU HEAR WHILE SERVING ON A JURY? Witness, Honorable , one of the Justices of the Court in County, day of , 20 IN HOW MANY OF THOSE CASES DID THE JURY REACH A VERDICT? above and type name below) (Attorney must sign IN HOW MANY OF THOSE CASES DID YOU SERVE AS THE JURY FOREPERSON? Attorney(s) for WAS YOUR JURY SERVICE A POSITIVE OR NEGATIVE EXPERIENCE? 1.25 IF YOU HAVE EVER BEEN TO COURT FOR ANY OTHER REASON (EXCLUDING DIVORCE), EXPLAIN: Office and P.O. Address Form Approved by the Judicial Council of California MC-001 [Effective January 1, 2004] Optional Form Telephone No.: Facsimile No.: E-Mail Address: JUROR QUESTIONNAIRE FOR CIVIL CASES/General Questions 3 Mobile Tel. No.: C-3 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. 1.26 IF YOU PERSONALLY KNOW ANY JUDGES OR ATTORNEYS OR COURT PERSONNEL, WHAT ARE THEIR NAMES AND RELATIONSHIP TO YOU? : Plaintiff(s) 1.27 Calendar No. : JUDICIAL SUBPOENA -against: DESCRIBE ANY PROBLEMS (VISION, HEARING, OR OTHER MEDICAL PROBLEMS) THAT MAY AFFECT YOUR JURY SERVICE: : : Defendant(s) IF YOU OR ANYONE CLOSE TO YOU HAS EVER MADE ANY TYPE OF CLAIM FOR DAMAGES, EXPLAIN: : ...................................................... 1.28 THE PEOPLE OF THE STATE OF NEW YORK TO 1.29 IF A CLAIM FOR MONEY DAMAGES HAS EVER BEEN MADE AGAINST YOU OR ANYONE CLOSE TO YOU, EXPLAIN THE CIRCUMSTANCES: GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of 1.30 IF YOU OR ANYONE CLOSE TO YOU HAS EVER SUED OR BEEN SUED IN ANY TYPE OF LAWSUIT, EXPLAIN: in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to all damages sustained as a result of your failure to comply. the party on whose behalf this DAMAGES AWARDED IN a maximum penalty of $50 and 1.31 DO YOU FEEL THAT MONEY subpoena was issued forLAWSUITS ARE (CHECK ONE): EXCESSIVE OCCASIONALLY TOO LOW OFTEN TOO LARGE OFTEN TOO LOW Witness, Honorable ABOUT RIGHT Court in County, 1.32 day of , one of the Justices of the , OTHER (SPECIFY): 20 IF YOU HAVE ANY ETHICAL, RELIGIOUS, POLITICAL, OR OTHER BELIEFS THAT MAY PREVENT YOU FROM SERVING AS A JUROR, EXPLAIN: (Attorney must sign above and type name below) Attorney(s) for 1.33 IF THERE IS ANY MATTER NOT COVERED BY THIS QUESTIONNAIRE THAT COULD AFFECT YOUR ABILITY TO BE A FAIR AND IMPARTIAL JUROR, EXPLAIN: Office and P.O. Address Form Approved by the Judicial Council of California MC-001 [Effective January 1, 2004] Optional Form Telephone No.: Facsimile No.: E-Mail Address: JUROR QUESTIONNAIRE FOR CIVIL CASES/General Questions 4 Mobile Tel. No.: C-4 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : JUROR QUESTIONNAIRE : Calendar No. FOR CIVIL CASES : JUDICIAL SUBPOENA Plaintiff(s) -against- Personal FULL NAME: 2.1 Index No. Injury Supplement : : IF YOU OR ANYONE CLOSE TO YOU HAS EVER BEEN INVOLVED IN AN ACCIDENT IN WHICH SOMEONE WAS : INJURED, EXPLAIN: Defendant(s) : ...................................................... 2.2 THE PEOPLE OFMARK STATE OF NEW YORK THE ON THE APPROPRIATE LINE(S) IF YOU OR ANYONE CLOSE TO YOU HAS EVER BEEN PLACE A CHECK EMPLOYED IN ANY CAPACITY BY ANY OF THE FOLLOWING TYPES OF BUSINESSES: OTHER PERSON TO YOURSELF ANY COURT IN THE STATE OF CALIFORNIA ATTORNEY, LAW FIRM, OR LAW OFFICE CLAIMS ADJUSTMENT, EVALUATION, REVIEW, SETTLEMENT, OR INVESTIGATION GREETINGS: WE COMMAND YOU, that allACCIDENTand excuses being laid aside, you and each of you attend before business INVESTIGATION OR LAW ENFORCEMENT DISABILITY, HEALTH, LIFE, CASUALTY, OR ACCIDENTAL INJURY , the Honorable at the Court BENEFITS OR PROGRAMS located at County of INVESTMENTS in room , on the day of ECONOMICS, ACTUARIAL, OR o'clock in the , 20 , at noon, and at any recessed HEALTH CARE DOCTOR, action on HOSPITAL, DENTAL, or adjourned date, to testify and give evidence as a witness in this NURSING, the part of the PHYSICAL THERAPY, PHARMACY, OR ANY RELATED FIELD 2.3 IF YOU CHECKED ANY LINE IN THE PREVIOUS QUESTION (2.2), PLEASE STATE THE RELATIONSHIP OF THAT PERSON TO YOU, THE TYPE AND DETAILS OF THAT EMPLOYMENT, AND THE YEARS OF THAT EMPLOYMENT: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable , one of the Justices of the Court in HAVE ANY BELIEFS AGAINST AWARDING DAMAGES FOR PERSONAL INJURY, PAIN, OR SUFFERING? County, day of , 20 2.4 DO YOU YES NO IF YES, EXPLAIN: (Attorney must sign above and type name below) Attorney(s) for 2.5 DO YOU OR ANY MEMBERS OF YOUR IMMEDIATE FAMILY OR HOUSEHOLD SEE A DOCTOR OR OTHER MEDICAL YES NO PRACTITIONER REGULARLY FOR ANY CONTINUING MEDICAL PROBLEM? IF YES, EXPLAIN: Office and P.O. Address Form Approved by the Judicial Council of California MC-001 [Effective January 1, 2004] Optional Form Telephone No.: Facsimile No.: E-Mail Address: JUROR QUESTIONNAIRE FOR CIVIL CASES/Personal Injury Supplement Mobile Tel. No.: D American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : JUROR QUESTIONNAIRE : Calendar No. FOR CIVIL CASES : JUDICIAL SUBPOENA Plaintiff(s) Verification -against- Index No. : : : Defendant(s) : ...................................................... I, , DECLARE UNDER PENALTY OF PERJURY THE PEOPLE OF THE STATENAME) OF NEW YORK (PRINT UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING RESPONSES I HAVE GIVEN ON THIS TO JUROR QUESTIONNAIRE, AND ON ANY ATTACHED SHEETS, ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Court in Witness, Honorable County, , one of the Justices of the day of , 20 .............................................................................................. .. (DATE) (SIGNATURE) (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Form Approved by the Judicial Council of California MC-001 [Effective January 1, 2004] Optional Form Telephone No.: Facsimile No.: E-Mail Address: JUROR QUESTIONNAIRE FOR CIVIL CASES/Verification Mobile Tel. No.: E American LegalNet, Inc. www.USCourtForms.com