APPENDIX B - JURY MANAGEMENT FORMS

WASHINGTON COUNTY COMMON PLEAS COURT
MARIETTA, OHIO
JUDGES
Susan E. Boyer
Ed Lane
Timothy A. Williams

JUROR QUESTIONNAIRE

1. Name_______________________________________ Age:____________
2. Home address: ______________________________________________
3. Phone numbers: home__________________ work__________________
4. Years of residence in Washington County_____________________
5. Education: Completed (Mark "x") or years attended:
   Grade School____________ High School______________
   College_________________ Grad. School_____________
   
6. Marital Status: Married___ Separated____ Widow/Widower______
   Single____ Divorced______ Number of children_____________
7. Your occupation and employer________________________________
   (if retired, write "Retired" and give Last occupation and employer)
8. Spouses occupation and employer ____________________________
   ___________________________________________________________
   (if widow/widower, give spouses last occupation and employer)
9. List living members of your family:(Spouse and children only)
   Living with you
   Relationship Age    Yes/No    occupation    Employer
   ________________________________________________________________
   ________________________________________________________________
   ________________________________________________________________
   ________________________________________________________________
   ________________________________________________________________
   
10. Have you ever been convicted of State of Federal felony?___
    If yes, describe the nature of the felony, year convicted, and release date from probation or parole: ___________________________________________________________
11. Have you ever served as a juror before?____________. If
    yes, when and where?_______________________________________
12. Have you, or any member of your family listed above, been sued, or sued another person?__________. If yes, complete the following: Type of lawsuit_____________________________ When____________What Court_________________________________
13. Have you, or any member of your family listed above, ever suffered any bodily injury? Yes______ No______
14. Have you, or any member of your family listed above, been the victim of a crime? Yes ______ No______
15. Has a claim for personal injury ever been made against you or your family NOT INVOLVING A LAW SUIT? Yes____ No____
16. Are you related to, or a close friend of, any law enforcement officer? Yes______ No_______
17. Do you drive an automobile? Yes______ No_______
18. Name of your attorney, if any? ____________________________
19. Are you, or any members of your immediate family, stockholders in any insurance casualty company, automobile or otherwise, or are they employed by any automobile liability insurance or casualty company? Yes_____ No_____
20. Are you, or any members of your immediate family, connected in any way with any insurance agency that sells automobile liability or casualty insurance? If so, name the company, the member of you family and the agency. ___________________________________________________________
21. Are you, or any members of your immediate family, employed by the Ohio Bureau Workers Compensation and Industrial Commission? Yes______ No______
22. Are you, or any members of your immediate family, connected in any way with any health and accident insurance company, such as Blue Cross, or any similar company that sells health and accident insurance? Yes_____ No_____
23. Name your automobile casualty insurance company, if any._______________________________________________________

State of Ohio
Washington County

I do hereby solemnly (swear or affirm) that the answers to the foregoing question are true and correct to the best of my knowledge and belief.

Date:____________________ _____________________________________
                                                          (Signature)

©2006 Washington County
ALL RIGHTS RESERVED