Jury Service Questionnaire – Fairfield County

Juror Number Name Age Sex

Are you a citizen of the United States?

Yes No

Street Address

City

Zip Code

How long have you resided in Fairfield County?

Home Phone

Work Phone

Cell Phone

E-Mail

Marital Status

Single Married Separated/Divorced Widow(er)

Occupation and Current Employer

Education (check all that apply)

Grade School High School Community College Bachelor's Graduate/Doctorate Degree Other:

1. Family Details

Please list information regarding spouse and children:

Name	Relationship	Age	Lives With You? (Y or N)	Occupation & Employer
Row 1 Name	Row 1 Relationship	Row 1 Age	Row 1 Lives With You	Row 1 Occupation and Employer
Row 2 Name	Row 2 Relationship	Row 2 Age	Row 2 Lives With You	Row 2 Occupation and Employer
Row 3 Name	Row 3 Relationship	Row 3 Age	Row 3 Lives With You	Row 3 Occupation and Employer
Row 4 Name	Row 4 Relationship	Row 4 Age	Row 4 Lives With You	Row 4 Occupation and Employer
Row 5 Name	Row 5 Relationship	Row 5 Age	Row 5 Lives With You	Row 5 Occupation and Employer

2. Medical/Impairment Details

a. Do you have any eye sight or hearing impairment that may affect your ability to serve as a juror?

Yes No

If yes, explain:

b. Do you have any other physical disability that may affect your ability to serve as a juror?

Yes No

If yes, explain:

c. Have you or an immediate family member ever had medical treatment for any serious illness/disability?

Yes No

If yes, explain:

3. Criminal/Legal History

a. Have you ever been convicted of a state or federal felony offense? (This does NOT include misdemeanors or traffic offenses)

Yes No

If yes, explain:

b. Have you, a family member, or close friend ever been the victim of a crime?

Yes No

If yes, explain:

c. Are you related to, or a close friend of, any law enforcement officer or prosecutor?

Yes No

If yes, explain:

d. Have you or any member of your immediate family been involved in a lawsuit of any kind?

Yes No

If yes, what type, where, and when?

e. Have you ever served on a jury before?

Yes No

If yes, when and in what court?

4. Insurance/Miscellaneous Questions

a. Have you or any of your immediate family members worked for an automobile insurance or health insurance company?

Yes No

If yes, who and for what company?

b. Do you carry automobile insurance?

Yes No

If yes, with what company?

c. Have you or any of your immediate family members worked for the Ohio Bureau of Workers' Compensation or the Industrial Commission?

Yes No

If so, who and in what capacity?

d. Do you have any difficulty reading or understanding English?

Yes No

If yes, explain:

e. If selected, do you feel you have the ability to serve as a fair and impartial juror?

Yes No

If no, explain:

The answers to the above questions are true to the best of my knowledge and belief.