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 Click to view Image | SINGLE Click to view Image | SEPARATED Click to view Image | DIVORCED Click to view Image | WIDOWED Click to view Image |
OCCUPATION | OCCUPATION(S) PAST 10 YEARS | |||
OCCUPATION OF SPOUSE/ OTHER | PAST 10 YEARS OCCUPATION OF SPOUSE/OTHER | |||
NUMBER OF CHILDREN | RACE: Click to view Image WHITEClick to view Image BLACKClick to view Image HISPANIC Click to view Image 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? | Click to view Image | Click to view Image |
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? | Click to view Image | Click to view Image |
3. | Do you have any physical or psychological disability that might interfere with or prevent you from serving as a juror? | Click to view Image | Click to view Image |
4. | Have you or anyone close to you ever been the victim of a crime? | Click to view Image | Click to view Image |
5. | Have you or anyone close to you ever been charged with or arrested for a crime, other than a traffic violation? | Click to view Image | Click to view Image |
6. | Have you or anyone close to you ever been an eyewitness to a crime, whether or not it ever came to court? | Click to view Image | Click to view Image |
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. | Click to view Image | Click to view Image |
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? | Click to view Image | Click to view Image |
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? | Click to view Image | Click to view Image |
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? | Click to view Image | Click to view Image |
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? | Click to view Image | Click to view Image |
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? | Click to view Image | Click to view Image |
13. | In general, would you have any problem following and applying the judge’s instruction on the law? | Click to view Image | Click to view Image |
14. | Would you have any problem during jury deliberations in a criminal case discussing the case fully but still making up your own mind? | Click to view Image | Click to view Image |
15. | Are you presently taking any medication that might interfere with or prevent you from serving as a juror? | Click to view Image | Click to view Image |
16. | Is there any other reason you could not be a fair juror in a criminal case? | Click to view Image | Click to view Image |
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
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DATE
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234 Pa. Code § 632
Committee Explanatory Reports:
Final Report explaining the March 1, 2000 reorganization and renumbering of the rules published with the Court’s Order at 30 Pa.B. 1478 (March 18, 2000).
Final Report explaining the July 7, 2015 amendments correcting cross-references to Rules 625 and 631 published with the Court’s Order at 45 Pa.B. 3985 (July 25, 2015).