Juror Name

JUROR QUESTIONNAIRE

Trial by jury is the keystone of our system of justice. Jury service is therefore both an opportunity and an obligation of every American citizen. This is a questionnaire, not a summons for jury service. Your name has been drawn from a combined list of drivers/voters/identification card and Illinois disabled person ID card-holders of Champaign County. You are being considered for jury service in the Champaign County Circuit Court. This is a way of obtaining (for office courthouse use ONLY) some information about you from which we can objectively determine whether you are qualified to serve as a juror pursuant to state law. If we find you qualified, you MAY be summoned at a later date.

SECTION A
QUALIFICATIONS

Respond completely to the following questions so that we may determine if you meet the statutory requirements for jury service in this jurisdiction.
  1. ARE YOU AT LEAST 18 YEARS OF AGE?

    Yes No

  2. ARE YOU A CITIZEN OF THE UNITED STATES?

    Yes No

  3. ARE YOU A CURRENT RESIDENT OF CHAMPAIGN COUNTY, ILLINOIS?

    Yes No

  4. ARE YOU A PARTY TO ANY LAWSUIT NOW PENDING IN CHAMPAIGN COUNTY?

    Yes No

    AS A PLAINTIFF?

    Yes No

    AS A DEFENDANT?

    Yes No

  5. DO YOU READ AND WRITE THE ENGLISH LANGUAGE?

    Yes No

  6. DO YOU SPEAK AND UNDERSTAND THE ENGLISH LANGUAGE?

    Yes No

  7. DO YOU REQUIRE ACCOMMODATIONS BECAUSE OF ANY DISABILITY?

    Yes No

  8. DO YOU HAVE A PHYSICAL OR MENTAL DISABILITY THAT WOULD INTERFERE WITH OR PREVENT YOU FROM SERVING AS A JUROR?

    Yes No
SECTION B
EXEMPTIONS

THIS SECTION DESCRIBES CERTAIN CATEGORIES OF PERSONS WHO MAY BE EXCUSED FROM SERVICE AS A JUROR. IF YOU ARE A PERSON IN ONE OF THESE CATEGORIES AND YOU WISH TO BE EXCUSED, MARK THE RESPONSE FOR THE LETTER OF YOUR CATEGORY HERE.

  1. ARE YOU A PERSON WHO HAS SERVED AS A GRAND OR PETIT JUROR WITHIN THE LAST (1) YEAR. (GIVE NAME OF COURT AND DATES YOU SERVED IN THE REMARKS SECTION AT THE BOTTOM OF THIS PAGE)

  2. A PERSON WHO IS ESSENTIAL TO THE CARE OF AGED OR INFIRM PERSON OR A CHILD UNDER THE AGE OF 12. (EXPLAIN FULLY IN THE REMARKS SECTION, LIST INFIRMIT OR CHILD AND RELATIONSHIP)

  3. A PERSON WHOSE OWN AGE OR HEALTH WOULD NOT ALLOW THEM TO SERVE. (EXPLAIN FULLY IN THE REMARKS SECTION AT THE BOTTOM OF THIS PAGE)

  4. A PERSON FOR WHOM JURY SERVICE WOULD CONSTITUTE A SEVERE HARDSHIP.

  5. A NURSING MOTHER WHO WISHES TO BE EXCUSED FROM JURY SERVICE.

  6. OTHER (EXPLAIN FULLY IN THE REMARKS SECTION AT THE BOTTOM OF THIS PAGE)

SECTION C
ACCOMODATIONS




SECTION D
BIOGRAPHICAL INFORMATION




  2. PLEASE INDICATE YOUR SEX:

    Male Female

  3. DO YOU HAVE CHILDREN?

    Yes No




  4. OTHER:


  5. IF YOU ARE CURRENTLY EMPLOYED, PLEASE COMPLETE THE FOLLOWING:

    YOUR OCCUPATION:



    EMPLOYER'S NAME:



    YEARS THERE:



  6. IF YOUR SPOUSE/PARTNER IS CURRENTLY EMPLOYED, PLEASE COMPLETE THE FOLLOWING:

    SPOUSE/PARTNER OCCUPATION:



    EMPLOYER'S NAME:



    YEARS THERE:



  7. HAVE YOU OR A CLOSE FAMILY MEMBER BEEN THE VICTIM OF A CRIME?

    Yes No

  8. RACE: Federal law requires no race discrimination in the juror selection process. This answer is required solely to avoid discrimination in juror selection and has absolutely no bearing on qualifications for jury service. By answering this question you help the Circuit Court to check and observe the juror selection process so that discrimination cannot occur. In this way, the Circuit Court can fulfill this policy, which is to provide jurors who are randomly selected from a fair cross section of the community. Fill in the response which best describes your race.








    9. ARE YOU HISPANIC?

    Yes No








SECTION E - CONFIDENTIAL INFORMATION

REMARKS:

Home Phone Number:


Work Phone Number:


Cell Phone Number:


Email:


CERTIFY

I declare under penalty of perjury that all answers are true and correct to the best of my knowledge and belief.