Hernandez v. Valley View Hospital Association et al

Filing 245

Amended ORDER Approving Juror Questionnaire by Judge Robert E. Blackburn on 01/15/14. (Attachments: # 1 Juror Questionnaire) (jjhsl, )

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JUROR QUESTIONNAIRE 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. 1. What is your name? ____________________________________________ Your gender? M or F 2. In what city and county do you reside? ________________________ 3. Age? ________ Marital Status? _________ Children? (#, ages, & gender) ____________________________ 4. Where were you born and raised? _____________________ How long at current address? ______________ 5. Are you regularly employed, self employed, or unemployed? ________________________________________ 6. Occupation and employer? (If retired, prior occupation and employer) _______________________________ Spouses occupation? _________________________________ ____________________________________ 7. Level of education/degrees? ________________________________________________________________ 8. Law enforcement experience and/or military service experience, if any?_______________________________ 9. Have you ever been on a jury before? ______if yes, when? __________ Type of case? ______________ 10. Organizations or clubs to which you belong? ____________________________________________________ ________________________________________________________________________________________ 11. Hobbies and leisure activities: _______________________________________________________________ 12. 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? ________________________________ __________________________________________________________________________________________ 13. Have you ever been a witness or a party to any civil proceeding? __________ When and what type of case?___________________________________________________________________________________ 14. How do you keep up with the news? __________________________________________________________ 15. Have you heard, seen, or read anything about this case from any source? If so, please explain. Be specific: ________________________________________________________________________________________ 16. 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): ____________________________________________________________ 17. 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. Dated: ______________________________ Signed:____________________________________________ Print Name: ________________________________________

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