The trial judge may make such other order to protect the copies as is appropriate.
JUROR INFORMATION QUESTIONNAIRE
CONFIDENTIAL; NOT PUBLIC RECORD
NAME:LAST | FIRST | MIDDLE INITIAL | ||
CITY/TOWNSHIP | COMMUNITIES IN WHICH YOU RESIDED OVER THE PAST 10 YEARS: | |||
MARITAL STATUS: MARRIED [] | SINGLE [] | SEPARATED [] | DIVORCED [] | WIDOWED [] |
OCCUPATION | OCCUPATION(S) PAST 10 YEARS | |||
OCCUPATION OF SPOUSE/ OTHER | PAST 10 YEARS OCCUPATION OF SPOUSE/OTHER | |||
NUMBER OF CHILDREN | RACE: [] WHITE [] BLACK [] HISPANIC [] OTHER | |||
LEVEL OF EDUCATION YOURS | SPOUSE/OTHER | CHILDREN |
YES | NO | ||
1. | Have you ever served as a juror before? If so, were you ever on a hung jury? | [] | [] |
2. | Do you have any religious, moral, or ethical beliefs that would prevent you from sitting in judgment in a criminal case and rendering a fair verdict? | [] | [] |
3. | Do you have any physical or psychological disability that might interfere with or prevent you from serving as a juror? | [] | [] |
4. | Have you or anyone close to you ever been the victim of a crime? | [] | [] |
5. | Have you or anyone close to you ever been charged with or arrested for a crime, other than a traffic violation? | [] | [] |
6. | Have you or anyone close to you ever been an eyewitness to a crime, whether or not it ever came to court? | [] | [] |
7. | Have you or anyone close to you ever worked in law enforcement or the justice system? This includes police, prosecutors, attorneys, detectives, security or prison guards, and court related agencies. | [] | [] |
8. | Would you be more likely to believe the testimony of a police officer or any other law enforcement officer because of his or her job? | [] | [] |
9. | Would you be less likely to believe the testimony of a police officer or other law enforcement officer because of his or her job? | [] | [] |
10. | Would you have any problem following the court's instruction that the defendant in a criminal case is presumed to be innocent unless and until proven guilty beyond a reasonable doubt? | [] | [] |
11. | Would you have any problem following the court's instruction that the defendant in a criminal case does not have to take the stand or present evidence, and it cannot be held against the defendant if he or she elects to remain silent or present no evidence? | [] | [] |
12. | Would you have any problem following the court's instruction in a criminal case that just because someone is arrested, it does not mean that the person is guilty of anything? | [] | [] |
13. | In general, would you have any problem following and applying the judge's instruction on the law? | [] | [] |
14. | Would you have any problem during jury deliberations in a criminal case discussing the case fully but still making up your own mind? | [] | [] |
15. | Are you presently taking any medication that might interfere with or prevent you from serving as a juror? | [] | [] |
16. | Is there any other reason you could not be a fair juror in a criminal case? | [] | [] |
I hereby certify that the answers on this form are true and correct. I understand that false answers provided herein subject me to penalties under 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities.
SIGNATURE ____________ DATE ____________
234 Pa. Code r. 632