Juror Qualification Questionnaire

A two-part questionnaire courts use to confirm whether someone meets the requirements for jury service and to learn about their background. Covers residence, citizenship, language, history and any accommodations needed.

Use this template

In the Claude connectors directory

Juror no.

Part 1: eligibility requirements

1. Name

First Name

Last Name

2. Date of birth

3. Mailing address

Street Address

City

State / Province

ZIP / Postal Code

4. Round-trip miles from home to court

5. What county do you live in?

6. Indicate whether you live in a city, township or village

City Township Village

Name of the city, township or village you live in

7. Cell phone number

8. Home phone number

9. Alternate phone number

10. Email address

11. Are you a U.S. citizen?

Yes, by birth Yes, naturalized No

12. Do you understand English?

Yes Some No

13. Do you speak English?

Yes Some No

If you do not speak English, please explain

14. Are you physically and mentally able to carry out a juror's duties?

Yes Yes, with accommodations No

15. The law exempts people aged 70 or older. If you are 70 or older, do you still wish to serve?

Yes No I am under 70

16. Have you been paid as a juror in the past 12 months?

Yes No Not sure

If yes, where did you serve in the past 12 months?

When (date or month) did you serve in the past 12 months?

17. Have you ever been convicted of a felony (a crime punishable by more than one year in prison)?

Yes No Yes, but my civil rights were restored

In what state were you convicted?

In what year were you convicted?

Date

Signature

Sign here

Part 2: juror questionnaire

Juror no.

Name

First Name

Last Name

Indicate whether you live in a city, township or village

City Township Village

Name of the city, township or village you live in

3. What is your occupation?

4. What other occupations have you had in the last 10 years?

5. Have you held state, county or municipal office, or worked in law enforcement?

Public office Law enforcement Both Neither

If yes, please specify

6. What is the last school grade you completed or degree you earned?

8. Spouse's name

9. Spouse's occupation

10. Number of children living at home

12. Do you drive?

Yes, daily Yes, occasionally No

13 a. Have you, a family member or a close friend been in a serious traffic accident?

Me A family member A close friend No

13 b. Was alcohol involved?

Yes No I don't know

13 c. Who was injured?

14. Have you ever been a victim, witness, plaintiff or defendant in a criminal or civil case?

If yes, please explain

15. Have you ever been convicted of a crime?

Yes No Traffic violations only

If yes, what was it?

16. Do you need any special accommodations from the court to serve as a juror?

If yes, please explain the accommodations you would need

Date

Signature

Sign here

Declaration and submission

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