OUJI-CIV No. 1.2A

INTRODUCTORY INSTRUCTIONS - JUROR QUESTIONNAIRES

IN THE DISTRICT COURT OF _____________ COUNTY.

STATE OF OKLAHOMA

[Name],

Plaintiff,

v.

[Name],

Defendant.

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) Case No. ______

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JUROR QUESTIONNAIRE

Each prospective juror must complete and sign this stand ard juror questionnaire and a ny

supplemental questionnaire provided by the court. T his questionnaire and any supplemental

questionnaire shall be confidential and will be used by the judge and the attorneys to aid them in

selecting the jury in this case. If you do not understand a question, please indicate. If you do

not have enough room to give adequate explanation to your answer, please use the space in

question 24 for additional information. If there is any question that you would rather discuss with

the judge and attorneys priva tely outside the presence of other jurors, please mark the question

with an asterisk (*).

1. Name: _____________________________________________________________

(Last) (First) (Middle initial)

2. Sex: ( ) male ( ) female

3. Marital status: ( ) married ( ) never married ( ) separated ( ) divorced ( ) widowed

OUJI 3d (Rev. 2008) Chapter 1

4. Age: _____________

5. Place of birth: _________________________________________________________

6. Length of residency in Oklahoma (years): __________________________________

7. What county do you live in? ____________________________________________

8. List other places (city and state) you have lived: ___________________________

9. What is your occupation? ______________________________________________

(If retired or unemployed, write retired or unemployed and give your previous occupation.)

10. If you are currently employed outside the home, please provide:

Name of employer: ______________________________________________________

Job title: ______________________________________________________________

Length of time worked there: _____________________________________________

11. List other types of jobs you have held as an adult: __________________________

______________________________________________________________________

______________________________________________________________________

12. Educational background: ________________________________________________

______________________________________________________________________

______________________________________________________________________

13. If you attended college or vocational school, specify your major areas of study and any

degrees or certificates you earned and whether you have taken any course in law:

____________________________________________________________________

________________________________________________________________________

14. If you have had military experience, state your highest rank, branch of service, length of

service, and specify whether service was reserve or active duty: __________

______________________________________________________________________

______________________________________________________________________

15. List the organizations that you belong to or participate in, and the offices, if any, that you

hold in these organizations: ________________________________________

______________________________________________________________________

______________________________________________________________________

OUJI 3d (Rev. 2008) Chapter 1

16. If you are married, state spouse’s full name, occupation and employer: _________

_______________________________________________________________________

______________________________________________________________________

17. If you have any children or step children, please provide the following information:

Child # 1: sex ___ age ____ occupation _____________________________________

Child # 2: sex ___ age ____ occupation _____________________________________

Child # 3: sex ___ age ____ occupation _____________________________________

Child # 4: sex ___ age ____ occupation _____________________________________

18. Have you ever served as a juror? ( ) yes ( ) no

If yes, please provide the following information:

Year Court/location Type of case were you the foreperson?

____ ___________________ _______________ ( ) yes ( ) no

____ ___________________ _______________ ( ) yes ( ) no

____ ___________________ _______________ ( ) yes ( ) no

19. Have you ever appeared as a witness in any court proceedi ng, either civil criminal or

military? ( ) yes( ) no

If yes, when and in what court? ____________________________________________

________________________________________________________________________

_______________________________________________________________________

20. Have you or any member of your immediate family been a party to any kind of lawsuit or

court proceeding? Include all of the following:

Criminal ( ) yes( ) no

Bankruptcy ( ) yes( ) no

Civil ( ) yes( ) no

Workers’ compensation ( ) yes( ) no

Divorce ( ) yes( ) no

Other ( ) yes( ) no

OUJI 3d (Rev. 2008) Chapter 1

If yes to any, state when and in what court as to each __________________________

_______________________________________________________________________

_______________________________________________________________________

______________________________________________________________________

21. Have you, any family member, or any close friend ever worked for any attorney, a law

office? ( ) yes ( ) no

If yes, state each person’s name and relationship to you:

______________________________________________________________________

_______________________________________________________________________

Position held: __________________________________________________________

Name of attorney or law office: ______________________________________________

Dates of employment: _____________________________________________________

22. Have you, any family member, or any close friend ever worked in law enforcement? ( ) yes

( ) no

If the answer is yes, please identify the name of the person(s) so employed, the particular agency

or department(s), the position held for such agency or department(s), and the years of

employment:

______________________________________________________________________________

_____________________________________________________________

23. Are you presently taking medicine or have any hearing or other health issue which may

affect your ability to serve as a juror? ( ) yes ( ) no

If yes, please explain: ____________________________________________________

_______________________________________________________________________

______________________________________________________________________

24. Is there any reason you could not serve as a juror? ( ) yes ( ) no

If yes, please explain: ____________________________________________________

_______________________________________________________________________

OUJI 3d (Rev. 2008) Chapter 1

______________________________________________________________________

25. Use this space for any additional comments: ______________________________

________________________________________________________________________

_______________________________________________________________________

I affirm that the forgoing is true and correct to the best of my knowledge and belief.

___________________________ ________________________________

(Date and Place) (Signature)