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Juror Questionnaire

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


 

I. Background Information


 

(Number is 9 digits and begins 100xxxxxx) (If you number begins with 900xxxxxx go to the State of Iowa E-Juror site at https://ejuror.iowa.gov/ejuror/webapp/login )

 

A. Residence Information


 


 

B. Education Information


 


 

C. Employment Information


 

(If you are retired or disabled, respond below based on where you last worked)

 

D. Military Experience.


 


 

E. Family Information - Spouse/Significant Other


 

*complete the following section if applicable*

F. Family Information - Children *Complete the following if you have children*

*Complete the following if you have children*
If you have any adult children, what are their occupations? (If your adult child is a student, describe what he or she is studying).

II. INTERESTS, ACTIVITIES AND EXPERIENCES

A. Memberships


 

(eq. Union, professional group, civic group, special interest group, charitable foundation, or other similar organization?)

B. Interests and Activities


 

(including news programs)
(e.g., hunting, personal protection, target shooting, collection)?

C. Prior Jury Experience *Complete this section only if you have served on a jury*


 

For example a case where the defendant on trial was accused of committing a crime?

 


 

(eq, such as one involving personal injury, a contract or property dispute, employment discrimination, or a similar case?)
(Arrests for OWI-type offenses should be listed).
(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)
(including any former spouses, 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)
(e.g., personal injury, contract, employment, small claims)?

 

F. General Matters


 


 

G. Health


 


 

Request to be excused


 

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 entering a date and typing your name in the signature area at the bottom and then 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.

 

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 301
Sioux City, IA 51101

NOTE: Fax number available upon request.

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