Jury questionnaire – slip and fall personal injury lawsuit

What is a jury questionnaire?

Jury selection in a slip and fall case usually involves the judge and/or the injury attorneys for both sides asking questions, in open court, of each person summoned for jury duty that day. Sometimes, as a preliminary matter, all the potential jurors are asked to fill out a written jury questionnaire. The attorneys for both sides review the questionnaires, before meeting with the jurors in open court, to see if any particular answers stand out. The goal of the questionnaire, then, is to streamline the open-court questioning and make the entire process of jury selection more efficient.

Sample questionnaire for a slip and fall case

Below is a written jury questionnaire that might be used in the trial of a slip and fall personal injury lawsuit:

This is a slip and fall case.

Thank you for coming to court as a potential juror. Before this case can start, a jury must be selected. The judge and the personal injury attorneys involved in the case need to know something about you in order to select jurors who can be fair to both sides.

Everyone has attitudes and opinions that are shaped by their life experiences. Sometimes these experiences can make it difficult to look at certain issues in an unbiased and unemotional way. As a juror, you must return a verdict based on the law and on the facts proved in court, not on emotion or on other views not supported by the evidence. The judge will give you instructions on the law 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 personal injury lawyers for both sides learn something about your background and your view on issues that may be related to this slip and fall case. The questions are asked not to invade your privacy, but to make sure that you can be a fair and impartial juror. If there is any reason why you might not be able to give both sides a fair trial in this slip and fall case, it is important that you say so.

Please respond to the following questions as completely as possible. If there is anything you do not want to talk about in open court, please circle the question number. After you have finished the questionnaire, let the clerk know that you have circled one or more question numbers. Do not write on the back of any page. Use the sheet of paper attached. If you have trouble reading, understanding, or filling out this form, please let the court clerk know.

YOU ARE ANSWERING THESE QUESTIONS UNDER PENALTY OF PERJURY. YOUR ANSWERS MUST BE TRUE AND COMPLETE.

THANK YOU FOR YOUR HELP IN SELECTING A FAIR JURY.

Name: __________________________________________

Juror Number:_________________

1. Age: _______ Sex: Male____ Female_____ Race/Ethnicity:_________________

2. Do you speak and understand English? _____ Yes _____ No

3. Do you speak any other languages besides English? _____ Yes _____ No
If YES, what other languages do you speak: _________________________________________________

4. How long have you lived in [state]? __________________

5. Neighborhood or community where you currently live: ____________________
How long have you lived there? _____________

6. Where else have you lived (place and dates)? ___________________________
Where were you born? __________________________________

7. Do you currently own or rent your home? Own _______ Rent _______ Other: (explain) ______________________________.
When was your house or apartment where you currently live built? ______

8. Have you ever owned any property that you rented to someone else?
_______ Yes, now.
_______ Yes, in the past.
_______No
If YES, please describe when you rented the property, to whom you rented the property and the type of property (a house, an apartment building, etc.). __________________________________________________________________________________________________________________________________________________________________

9. Has a governmental agency ever taken any action with respect to your property? (e.g. has your property ever been condemned, declared a public nuisance, a subject of a violation, etc)?
_______ Yes
_______ No
If YES, please describe what happened and when. __________________________________________________________________________________________________________________________________________________________________

10. Has any individual or private entity brought an action against you as a property owner/lessor/lessee?
_______ Yes _______ No
If YES, please describe what happened and when.
__________________________________________________________________________________________________________________________________________________

11. Your employment status:
_____ Currently employed full-time
_____ Currently employed part-time
_____ Unemployed, looking for work since _______________ (date)
_____ Unemployed, not looking for work since _______________ (date)
_____ Full-time homemaker
_____ Full-time student
_____ Retired since _______________ (date)
_____ Disabled since _______________ (date)
_____ Other (specify) __________________________________________________________

12. If currently employed:

Your Occupation: ___________________________________________
Employer: ___________________ For how long: _____ Number of employees at your work ______
Your job responsibilities: _______________________________________________________
Do you supervise others:_____ Yes _____ No If YES, how many: _______________
Do you have any responsibility for hiring or firing: _____ Yes _____ No
Are you looking to change your current employment:_____ Yes _____ No
If YES, why: ________________________________________________
How satisfied are you with your current work situation?
_____Very satisfied _____ Not at all satisfied
_____Somewhat satisfied _____ Not Working

13. If you are not currently employed:
Your last employer: ____________________ For how long: ___________
Your occupation: _______________
Number of employees at your last place of work: __________________
Your job responsibilities: _______________________________________________________
Did you supervise others _____ Yes _____ No
If YES, how many? ___________
Did you have any responsibilities for hiring or firing? ____Yes ___No
Reason for leaving:_________________________________________________

14. Please state any past occupations or types of work and employers. If retired or disabled, indicate your occupations prior to retirement or disability. Briefly describe each job.

Occupation/Employer Dates Job Description
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

15. Please describe your education:

School Degree/Certificate Area of Study Dates
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What were your favorite classes in school? ___________________________________

16. Do you hold any professional or vocational licenses or certificates?
_____ Yes _____ No
If YES, specify: ________________________________________________________________

17. Do you have any special training or skills?
If YES, specify: ________________________________________________________________

18. Do you plan to attend or are you currently attending school?
_____ Yes _____ No
If YES, please explain: ____________________________________

19. Your marital status:
_____ Single and never married
_____ Currently married and have been for _____ years
_____ Single, living with significant other for _____ years
_____ Single, but married in the past for _____ years
_____ Widowed/widower, married in the past for _____ years
_____ Other: ___________________________________
How many times have you been married? ______

20. Please provide the following information about your spouse or significant other:

a. Current employment status of your spouse or significant other?
_____ Currently employed full-time _____ Currently employed part-time
_____ Unemployed, looking for work _____ Unemployed, not looking for work
_____ Full-time homemaker ______ Retired since ___________(date)
_____ Full-time student _____ Disabled since ___________(date)
_____ Other (specify):___________________________________________________________

b. Current occupation: ____________________
Employer: ________________________
Number of years employed: ________

c. If retired or not currently employed, what was his/her:
Past occupation: _______
Past employer: _________________________
Number of years employed:_________
Number of years since he/she stopped working: _________

d. Education of your spouse/significant other:
School Degree/Certificate Area of Study Dates
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does he/she hold any professional or vocational licenses or certifications?
_____ Yes _____ No
If YES, specify: ______________________________________________________

e. Age of your spouse/significant other: _____ years

f. How long have you been together as a couple? _____ years

20. Occupations of your parents or other persons who raised you? (List even if retired or deceased)
Mother: __________________ Father: ________________¬¬¬¬¬¬
Other person(s) – Who/Occupation: ____________________________________________
a. If you, your current spouse or a person with whom you currently live has ever served in the military, please list for each the branch of the service and dates of service:
____________________________________________________________________________________________________________________________________________________________

b. If you have children, please state:
Sex Age live w/ you? Education Occupation
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

21. Please indicate the following information for each adult (other than your spouse/partner) who lives in your household on a regular basis, even if not living there full-time.

Person’s Relationship Age/ Occupation Length
to you Sex and Employer of Employment
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

22. Have you ever been self-employed or owned a business? _____ Yes _____ No
If YES, how many employees? _____
What type of business? ________________________________________________________
How long were you in this business? __________________________________________
Do you currently own the business? ____ Yes _____ No
If NO, why not? _______________________________________________________________

23. Have you or any family members ever had any educational or job-related training or experience in any of the following fields:

Yes, Self Yes, Family No

Law _________ ____________ ____
Healthcare _________ ____________ ____
Medicine _________ ____________ ____
Insurance _________ ____________ ____
Social Work _________ ____________ ____
Education _________ ____________ ____
Environmental regulation _________ ____________ ____
Real Estate _________ ____________ ____ Property management/
maintenance _________ ____________ ____ Electrical work _________ ____________ ____ Engineering _________ ____________ ____ Architecture _________ ____________ ____ Construction _________ ____________ ____ Building Inspection _________ ____________ ____ Painting _________ ____________ ____

a. If YES to the previous question, please explain:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

b. Are you a member of or an active supporter of any environmental group?
_____ Yes _____ No
If YES, which group(s)?________________________________________________

c. Please list all social, civic, religious, or other clubs or organizations to which you belong, or in which you participate. Please list leadership roles, if any:
____________________________________________________________________________________________________________________________________________________________

24. Have you or any family members ever worked for:

Yes, Self Yes, Family No
A law firm or lawyer __________ _____________ ____
The court system __________ _____________ ____ The legislature __________ _____________ ____
If YES, please explain:
____________________________________________________________________________________________________________________________________________________________

25. Have you ever worked for a large corporation?
_____Yes, now.
_____Yes, only in the past
_____No

26. Have you had any first-hand experience or dealings with a large corporation?
_____ Yes
_____ No
If YES, was your experience generally positive or negative?
_____ Positive _____ Negative _____ Neither
Please explain your response:
____________________________________________________________________________________________________________________________________________________________

27. Have you or anyone close to you ever been injured on another’s property?
_____ Yes, myself.
_Yes, someone else.
_____¬_Yes, both.
______No.
If YES, please describe who it was, the nature of the injury and what happened.
____________________________________________________________________________________________________________________________________________________________

28. Have you or has anyone close to you ever been exposed to dangerous conditions on your own property or that of another?
_____ Yes, myself _____ Yes, someone else _____Yes, both _____No
If YES, please describe who it was, the nature of the exposure and what happened.
____________________________________________________________________________________________________________________________________________________________

29. Have you ever lived in a house or an apartment that you believe contained a dangerous or defective condition?
_____ Yes _____ No _____Don’t know
If YES, explain: ____________________________________________________________________________________________________________________________________________________________

30. Have you ever worked in a building that you believe contained a dangerous or defective condition?
_____ Yes _____ No _____Don’t know
If YES, explain: ____________________________________________________________________________________________________________________________________________________________

31. Do you know anyone (including yourself) who has been involved in a lawsuit involving a claim of dangerous or defective conditions in or on property?
_____ Yes _____ No
If YES, please describe who it was and the lawsuit:
____________________________________________________________________________________________________________________________________________________________

32. Do you have any concerns about your health?
_____ Yes _____ No
If YES, please describe what your concerns are.
____________________________________________________________________________________________________________________________________________________________

33. Do you have any concerns about your family members’ health?
_____ Yes ______ No
If YES, please describe whose health and what your concerns are.
____________________________________________________________________________________________________________________________________________________________

34. Have you read or heard anything in the media or in conversation about the health risks associated with living in a home or dwelling with dangerous or defective conditions?
_____ Yes ______ No
If YES, what have you read or heard?
____________________________________________________________________________________________________________________________________________________________

35. To what extent, if any, are you concerned about the presence of dangerous or defective conditions in homes and buildings in your community?
_____ Very concerned ______ Somewhat concerned _____ Not concerned
If you are “very concerned” or “somewhat concerned,” please describe your concern.
____________________________________________________________________________________________________________________________________________________________

36. Have you read or heard anything in the media or in conversation about any lawsuit involving dangerous or defective conditions in or on property?
_____ Yes _____No
If YES, what have you read or heard?
____________________________________________________________________________________________________________________________________________________________

37. Have you formed any strong impression or do you have any strong opinion/feeling about any of the companies listed below? [This list will name all the defendants – that is, all the persons/entities who have been sued by the person injured in the slip and fall injury accident.]
_____________ _____ Yes ______________ _____ No
_____________ _____ Yes ______________ _____ No

38. If you indicated that you have an impression/opinion/feeling about any one of the companies listed above, please explain: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

39. Have you formed any strong impression or do you have any strong opinion/feeling about the amount of government regulation of homes, rental units and other buildings?
_____ Yes _____ No
If YES, what is your impression/opinion/feeling? ____________________________________________________________________________________________________________________________________________________________

40. Do you agree or disagree with each of the following statements?
a. Without a threat of multimillion dollar lawsuits, corporations would knowingly sacrifice the safety of their workers and the public in order to protect their profits.
_____ Agree _____ Unsure _____Disagree

b. When I hear that an individual has filed a lawsuit against a corporation, I usually think the corporation deserves blame and the individual deserves compensation.
_____ Agree _____ Unsure _____Disagree

c. It is not fair to judge a company’s health, safety and maintenance standards in the past by what is known about health, safety and maintenance today.
_____ Agree _____ Unsure _____Disagree

41. Do you know any attorneys, judges, or people involved in the court or legal system?
_____ Yes _____ No
If YES, please explain: ____________________________________________________________________________________________________________________________________________________________

42. Have you ever served on a jury?
_____ Yes _____ No
If YES:
When ____________ Civil case(s):__________ Criminal case(s) _______
Type(s) of lawsuit(s): _________________________________________________________
For each case, did the jury reach a verdict?_____________________________
Were you the foreperson? _____ Yes _____ No
How would you describe your experience(s): __________________________________

43. Have you or anyone close to you ever participated in the legal system, as a party, a witness, or as an expert? _____ Yes _____ No
If YES, please explain:
____________________________________________________________________________________________________________________________________________________________

44. Have you or has anyone close to you ever sued or been sued?
_____ Yes _____ No
If YES, please explain: ____________________________________________________________________________________________________________________________________________________________

45. Have you ever thought of suing someone or some entity, but did not?
_____ Yes _____ No
If YES, please explain: ____________________________________________________________________________________________________________________________________________________________

46. In general, do you believe jury monetary awards today are:
____ Too high ____ Too low ____ About right ____ No opinion

47. How frequently do you follow the news, either on radio, TV or in the newspaper?
_______ Several times a day
Sources: ___________________________________
_______ Once a day ____________________________________________
_______ Occasionally ____________________________________________
_______ Almost never ____________________________________________

48. What newspapers and magazines do you read regularly? ____________________________________________________________________
49. What are your favorite television shows?
____________________________________________________________________________________________________________________________________________________________

50. Do you use a computer?
______ Yes, at home _______ At home and at work
______ Yes, at work _______ No
If YES, for what purposes?
Home: _________________________________________________________________________
Work: __________________________________________________________________________
IF YES: How many hours per week do you spend on the Internet? _____

51. Are you generally satisfied with your financial condition?
_____ Very satisfied ______ Somewhat satisfied ______Not satisfied

52. Which of the following do you tend to consult and rely upon when you are making an important personal decision? Check all that apply.
_____Myself _____My family
_____My friends _____Experts
_____Written materials _____Religious Figure/church/prayer
_____Other

53. As a juror, after rendering a verdict for or against any party involved in this lawsuit, do you believe you will be judged any differently upon returning to your community? ____ Yes ____ No
Please explain: ____________________________________________________________________________________________________________________________________________________________

54. Describe any problem (vision, hearing, or other medical problems) that may affect your jury service: ____________________________________________________________________________________________________________________________________________________________

55. Do you have any philosophical, religious or other beliefs that would prevent you from sitting in judgment on this case?
_____ Yes _____ No If YES, please explain:
______________________________________________________________________________

56. Is there any other matter that could affect your ability to be a fair and impartial juror in this case?
_____ Yes _____ No If YES, please explain:
____________________________________________________________________________________________________________________________________________________________

57. Do you have any initial reaction to this slip and fall case based on what you have read or been told?
_____ Yes _____ No If YES, please explain: ____________________________________________________________________________________________________________________________________________________________

58. Do you recognize or think you might know any of the entities or people listed on Attachment A (witnesses)?
_____ Yes _____ No If YES, please write the name(s) here and explain:
____________________________________________________________________________________________________________________________________________________________

I, _________________________________, DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF [INSERT] THAT THE FOREGOING RESPONSES I HAVE GIVEN ON THIS JUROR QUESTIONNAIRE, AND ON ANY ATTACHED SHEETS, ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF

_________________________________
Date Signature

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