Juror Questionnaire
United States District Court
for the Northern District of Iowa


I. Background Information
Name:
Date of Birth:

A. Residence Information
City of Residence:
County:
With respect to your residence, do you:
How long have you lived at your current address?
In what city and state did you grow up?
B. Education Information
What is the highest education level you have completed?
Do you speak a language other than English?
If yes what language?
Do you regularly use a computer?
If yes, at:
C. Employment Information
Are you employed?
(If you are retired or disabled, respond below based on where you last worked)
If employed, where do you work?
How long have you worked at your current job?
What is your job title and/or duties?
Where did you work before that job?
How long did you work at that prior job?
What was your job title and/or duties?
D. Military Experience.
Have you ever been in the military?
If yes,
What was your branch and highest rank?
What were your duties?
When and where did you serve?
Were you honorably discharged?
E. Family Information - Spouse/Significant Other
What is your marital status?
*complete the following section if applicable*
Name of spouse/significant other:
Is this person employed outside of the home?
(If he or she is retired or disabled, respond below based on his or her last work)
If yes, where does he or she work?
How long has he or she worked at the current job? Years
What are his or her job title and or/duties?
Where did he or she work before the current job?
How long did he or she work at that job? Years
What were his or her job duties and/or title?
What is the highest educational level he or she completed?
F. Family Information - Children *Complete the following if you have children*
Age and gender of any children:
Do your children live with you?
Any additional information you wish to provide regarding your children's living arrangements:
If you have any adult children, what are their occupations? (If your adult child is a student, describe what he or she is studying).
G. Household Information - Other
Does anyone else live with you?
If yes, who else lives with you and what is their relationship to you?
II. INTERESTS, ACTIVITIES AND EXPERIENCES
A. Memberships
Have you ever been a member of any union, professional group, civic group, special interest group, charitable foundation, or other similar organization?
If yes, what organization(s) or group(s)?
Have you ever held a leadership position in the group(s)?
If yes, what position(s)?
B. Interests and Activities
What do you enjoy doing in your spare time?
What newspapers and magazines do our regularly read?
What radio programs do you regularly listen to?
What television programs, including news programs, do you regularly watch?
What websites or blogs do you routinely visit?
Do you, or does any member of your household, possess any firearms?
If yes, what type of guns?
How are they used (e.g., hunting, personal protection, target shooting, collection)?
C. Prior Jury Experience *Complete this section only if you have served on a jury*
Have you ever served on a jury in a criminal case, where the defendant on trial was accused of committing a crime?
If yes:
When was the trial?
Where was the trial?
Was the trial in state or federal court?
What crime(s) was/were alleged?
What was the verdict?
Were you the foreperson?
Have you ever served as a grand juror?
Have you ever served on a jury in a civil case, such as one involving personal injury, a contract or property dispute, employment discrimination, or a similar case?
If yes,
When was the trial?
Where was the trial?
Was the trial in state or federal court?
What was the lawsuit about?
Was the verdict?
Were you the foreperson?
How did your experience as a juror affect your thoughts about the legal system?
D. Prior Legal Experiences - Criminal System
Have you ever been arrested or charged with any criminal offense, other than a traffic violation?
(Arrests for OWI-type offenses should be listed).
If yes, provide details including when, and where, this occurred:
Were you convicted of the offense(s) alleged?
Have any of your close friends or family members been arrested or charged with any criminal offense, other than minor traffic offenses? (OWI-type offenses should be listed).
If yes, what is your relationship to that person?
What happened?
Have you ever been the victim of any crime?
If yes, what type of crime(s)?
Additional information you wish to share:
Have any of your close friends or family members been the victim of any crime?
If yes, what type of crime(s)?
What is your relationship to the victim?
Additional information you wish to share:
Do you have any law enforcement experience? (Include any educational programs or training attended, as well as any work for police departments, sheriff's offices, probation/parole offices, private investigators, or similar jobs).
If yes, describe this work or training:
Do any of your close friends or family members (including any former spouses) have any law enforcement experience? (Include any educational programs or training, as well as any work for police departments, sheriff's offices, probation/parole offices, private investigators, or similar jobs).
If yes, describe the individual, his or her relationship to you, and the nature of their work.
E. Prior Legal Experiences - Civil Matters
Have you ever been a party in a civil case?
If yes, were you:
What was the lawsuit about? (e.g., personal injury, contract, employment, small claims)?
Have any of your close friends or family members been a party in a civil case?
If yes,
What is your relationship to that person?
What was the lawsuit about?
Have you been injured in an accident or suffered from a severe medical condition?
If yes, describe the accident or condition:
Have any of your close friends or family members been injured in an accident or suffered from a severe medical condition?
If yes, describe the accident or condition:
Have you ever been a stock holder, director, officer, employee, or agent of any insurance company?
If yes, describe:
Do you have any close friends or family members who have ever been officers, directors, employees, or agents of any insurance company?
If yes, describe:
F. General Matters
Are any of your close friends or family members employed as an attorney or in a law office or legal department?
If yes, what is his or her relationship to you, what is their occupation, and where are they employed?
Do you have any opinions about the legal system (criminal or civil), or about any particular law?
If yes, describe:
Do you have any objections to, or concerns about, sitting as a juror?
If yes, describe:
Have you, your family, or close friends ever been affected by alcohol, drugs, or substance abuse in such a way that it would be difficult for you to serve as a juror?
If yes, describe:
Is there anything about your beliefs, values, or life experiences that would make it difficult for you to be a fair and impartial juror in a case involving someone of a particular race, ethnicity, citizenship, religion, age, gender, gender identity, or sexual orientation?
If yes, describe:
Do you know of any reason - not otherwise explained above - that you could not serve as a fair and impartial juror in any particular type of case?
If yes, describe:
G. Health
Do you have any physical or mental health condition(s) you believe could interfere with your ability to serve in a trial as a juror?
If yes, what?
What accommodations could be made to assist you in serving as a juror?

By typing my name into the signature block below, I declare under penalty of perjury that I am the person who completed this form and the answers above are true to the best of my knowledge and belief.
Signature:
Date:

Please list vacation dates or other prior commitment dates so we may try to work around these scheduled events.







If you intend to request an excuse from the court, please complete the following questions. If you are submitting this form online and do not plan to request an excuse, you are finished and can submit your form by clicking on the SUBMIT button.
REQUEST TO BE EXCUSED FROM JURY SERVICE
If you believe that you are entitled to be excused from jury service or that your term of service should be postponed, you must complete this form and return it to the Clerk’s office immediately along with your completed questionnaire.
FAILURE TO APPEAR AS DIRECTED, UNLESS YOU ARE EXCUSED, MAY SUBJECT YOU TO BEING HELD IN CONTEMPT OF COURT AND MAY RESULT IN A FINE OR IMPRISONMENT.
I request to be excused from jury duty for the following reasons:
1. The following medical condition(s) make it impossible for me to serve as a juror:
Please send an excuse from your doctor or an explanation of why you cannot secure such a statement to:

(Cedar Rapids)
US District Court
ATTN: Jury Administrator
111 7th Ave SE
Cedar Rapids, IA 52401

(Sioux City)
U.S. District Court
ATTN; Jury Administrator
320 6th St. Room 300
Sioux City, IA 51101

NOTE: Fax number available upon request.
2. I am the sole operator of a business, which would be required to shut down if I am absent for more than days. Please list the name and nature of the business:
3. Service as a juror would constitute an undue hardship for the following reasons (please be specific):
4. The following commitments make it impractical for me to serve as a juror at this time:
therefore I request my jury service be deferred until:


By typing my name into the signature block below, I declare under penalty of perjury that the foregoing is true and correct.


Date:
Signature:


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