New Mexico Forms Library

4-602C.  Juror questionnaire.

[For use with Rules 1-047, 2-603, 3-603 NMRA]

 

JUROR QUESTIONNAIRE FORM

 

Juror Badge Number: ___________

 

Please answer all questions, 1-20, and SIGN. The Juror Questionnaire will be provided to the attorneys, parties, and judges in all cases you may be selected to hear as a juror. The answers you provide will aid in the process of selecting a jury. If you do not understand a question, please place a question mark (?) next to the question. If you do not have enough room to answer the question, please use the space provided after question 20 or a separate sheet of paper. If there is a question you would rather discuss with the judge and attorneys in private, please indicate with an asterisk (*). Thank you for your cooperation.

 

1.         Legal name and former names:  ______________________________________

________________________________________________________________

 

2.         Gender:  _________________________________________________________

 

3.         Birth year:  _________________

 

4.         What is your race or ethnic background?  _______________________________

 

5.         In which neighborhood and/or area do you live?  _________________________

Where else have you lived (city, state, country)?  _________________________

 

6.         What is your marital status?  single _____  married _____

domestic partner _____  separated _____  divorced _____  widowed _____ 

 

7.         If you are married or in a domestic partnership, please provide spouse’s/partner’s full name and occupation. ___________________________________________

________________________________________________________________

 

8.         Do you have any children or step children? Yes _____  No _____

How many? ______  ages ___________  occupations ____________________

 

9.         Name of current or most recent employer and place of work: ________________

Occupation/job title and duties:  _______________________________________

Dates of employment:  ______________________________________________

 

10.       How many years of schooling have you completed?  ______________________

Highest level completed/degree  ______________________________________

Major areas of study:  ______________________________________________

 

11.       Do you belong to or participate in any religious, civic, social, union, professional, fraternal, political, or recreational organizations? Please list all: ________________________________________________________________

 

12.       Current political party affiliation:  ______________________________________

 

13.       Have you or any member of your immediate family been the victim of a crime?

Yes _____  No _____   If yes, who was the victim? _______________   What crime? _____________   When? ___________   Was an arrest made?

Yes _____  No _____

 

14.       Have you ever served as a juror?  Yes _____  No _____

(If yes please check)  Grand jury ______   Civil ______   Criminal ______

 

15.       Have you or anyone close to you ever sued anyone or been sued?

Yes _____  No _____

If yes, please explain: ______________________________________________

 

16.       Have you or an immediate family member ever been an agent, employee, or representative of an insurance company?  Yes _____  No _____

 

17.       Have you or an immediate family member been a defendant in a criminal case?

Yes _____  No _____

If yes, please explain:  ______________________________________________

 

18.       Have you or any family member ever been employed by a court, law enforcement agency,  jail or prison, or any attorney’s office?

Yes  _____  No _____

If yes, name of employer:  ___________________________________________

 

19.       Do you have a physical or mental disability of which we need to be aware? 

Yes ____  No _____

Are you presently taking any medication that may affect your ability to serve as a juror?  Yes _____  No _____

If yes, are there any special accommodations, services, or assistance we can provide during your jury service?  _____________________________________

 

20.       Is there any reason you could not serve as a juror?  Yes _____  No _____ (If you are requesting an excusal or postponement for this reason, you must complete and submit the Request for Postponement, Excusal, or Exemption Form)

If yes, please explain:  ______________________________________________

 

Use this space for any additional comments:  _________________________________

______________________________________________________________________

______________________________________________________________________

 

I SWEAR OR AFFIRM THAT THE INFORMATION I HAVE PROVIDED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.

 

________________________________ Signature of prospective juror, or preparer (if different than prospective juror)

_________________________________ Date

 

[Approved by Supreme Court Order No. 17-8300-016, effective December 31, 2017; as amended by Supreme Court Order No. 19-8300-022, effective December 31, 2019.]