Hernandez v. Valley View Hospital Association et al
Amended ORDER Approving Juror Questionnaire by Judge Robert E. Blackburn on 01/15/14. (Attachments: # 1 Juror Questionnaire) (jjhsl, )
You will help save time selecting a jury when you complete this questionnaire completely and accurately. Do not show or
discuss this questionnaire to or with anyone. The completed questionnaire is not a public document. Please print your
answers to all the questions, then print and sign your name below. Thank you.
Case Name: Teresa Hernandez v. Valley View Hospital Assoc.
What is your name? ____________________________________________ Your gender? M or F
In what city and county do you reside? ________________________
Age? ________ Marital Status? _________ Children? (#, ages, & gender) ____________________________
Where were you born and raised? _____________________ How long at current address? ______________
Are you regularly employed, self employed, or unemployed? ________________________________________
Occupation and employer? (If retired, prior occupation and employer) _______________________________
Spouses occupation? _________________________________ ____________________________________
Level of education/degrees? ________________________________________________________________
Law enforcement experience and/or military service experience, if any?_______________________________
Have you ever been on a jury before? ______if yes, when? __________ Type of case? ______________
Organizations or clubs to which you belong? ____________________________________________________
Hobbies and leisure activities: _______________________________________________________________
Have you, a member of your family, or a close friend been convicted of a crime, other than a traffic offense or
infraction, in the past ten years? ______ Who, what, when, and where? ________________________________
Have you ever been a witness or a party to any civil proceeding? __________ When and what type of
How do you keep up with the news? __________________________________________________________
Have you heard, seen, or read anything about this case from any source? If so, please explain. Be specific:
Do you believe there is any reason why you cannot be a fair and impartial juror in this civil case? _______
If yes, please give your reason(s): ____________________________________________________________
Is there anything you have not stated that might affect your jury service that you would like to discuss with the
Judge outside the presence of the other prospective jurors? _______
THANK YOU FOR YOUR HELP
I declare that the above information is true to the best of my knowledge. I know that if I have willfully misrepresented a material
fact on this questionnaire, I may be guilty of and punished under federal law for perjury or making a false statement.
Print Name: ________________________________________
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