JUROR QUESTIONNAIRE 
FOR CIVIL CASES
Code of Civil Procedure Section 205(c)-(d)

JURY-001

Sec. 1. Statutory Authority
This  Juror  Questionnaire  has  been  drafted  under  the  authority  of  Code  of  Civil  Procedure 
section 205(c)-(d) and is intended to expedite jury selection. It is not intended to alter statutes 
or rules governing the authority of the court or the role of counsel during voir dire.

Sec. 2. Use Notes for Courts
A. General
This Juror Questionnaire is intended for use in the court's discretion in appropriate civil cases. 
Its use in cases of brief duration may not be appropriate. Particular kinds of cases may require 
that this questionnaire be altered or augmented. The Personal Injury Supplement is intended 
to be used along with the General Questions in personal injury actions. Judges, in their own 
discretion, must determine what additional kinds of inquiry are appropriate in any given case.

B. Pre–Voir Dire Conference
The  court  should  confer  with  counsel  about  voir  dire  before  a  jury  panel  is  called.  At  this 
conference, the court may establish (1) guidelines for the use of the Juror Questionnaire, (2) 
any supplemental questions to be propounded to the panel by questionnaire, (3) the extent of 
the  court's  oral  inquiry  of  the  panel,  and  (4)  the  extent  of  oral  questioning  by  counsel. 
Proposed supplemental questions drafted by counsel should be filed and served at least three 
court  days  before  the  pre–voir  dire  conference.  Arrangements  for  duplication  of  completed 
questionnaires should be confirmed. The parties should share the cost of duplication.

C. Introduction of Questionnaire to Prospective Jurors
It  is  suggested  that  the  Juror  Questionnaire  be  used  after  the  court  has  given  its  customary 
introductory  remarks  and  any  additional  instructions  that  the  court  deems  appropriate.  The 
court also may wish to tell the panel members that a questionnaire will be used, to encourage 
complete  answers,  and  to  remind  them  that  their  answers  will  be  given  under  penalty  of 
perjury.  In  introducing  the  questionnaire,  the  court  should  instruct  prospective  jurors  how  to 
proceed if they have difficulty reading or filling out the form.

The court could direct that the Juror Questionnaire be given to prospective jurors by the jury 
commissioner  in  the  jury  assembly  room.  However,  this  procedure  ordinarily  will  mean  that 
jurors are not given complete instructions about the type of case they will hear or the identity 
of participants and witnesses. In addition, jurors who fill out the form before appearing in the 
trial  court  may  not  clearly  understand  that  their  answers  are  given  under  penalty  of  perjury. 
For these reasons, and to avoid the need to have jurors fill out supplemental questionnaires 
once  they  have  been  sent  to  the  trial  court,  it  is  strongly  recommended  that  the  Juror 
Questionnaire be used in the trial court setting.

Form Approved for Optional Use  
Judicial Council of California 
JURY-001 [Rev. September 1, 2018] 

JUROR QUESTIONNAIRE FOR CIVIL CASES/Code of Civil Procedure section 205(c)-(d)

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JUROR QUESTIONNAIRE 
FOR CIVIL CASES

Introduction and Instructions

JURY-001

Thank you for coming to court as a potential juror. Before the case can start, a 
jury  must  be  selected.  The  judge  and  the  people  involved  in  the  case  need  to 
know  something  about  you  in  order  to  select  jurors  who  can  be  fair  to  both 
sides.

Everyone  has  attitudes  and  opinions  that  are  shaped  by  their  life  experiences. 
Sometimes these experiences can make it difficult to look at a certain issue in 
an unbiased and unemotional way. As a juror, you must return a verdict based 
on  the  law  and  on  the  facts  proved  in  court,  not  on  emotion  or  on  other  views 
not  supported  by  the  evidence.  The  judge  will  give  you  instructions  on  the  law 
and  on  how  you  should  go  about  deciding  the  case.  You  must  listen  to  and 
follow the judge's instructions.

The questions on this form are designed to help the court and the lawyers learn 
something  about  your  background  and  your  views  on  issues  that  may  be 
related to this case. The questions are asked not to invade your privacy, but to 
make sure that you can be a fair and impartial juror. If there is any reason why 
you  might  not  be  able  to  give  both  sides  a  fair  trial  in  this  case,  it  is  important 
that you say so.

The judge has decided to use this form to save time and to give you a chance 
to tell the court and the lawyers about yourself.

In portions of this form, you will see the term "significant personal relationship." 
That  term  means  a  former  spouse,  domestic  partner,  life  partner,  or  anyone 
with  whom  you  have  an  influential  or  intimate  relationship  that  you  would 
characterize as important.

If there is anything you do not want to talk about in open court, please circle the 
question  number.  After  you  have  finished  the  questionnaire,  let  the  clerk  know 
that you have circled one or more question numbers.

Do not write on the back of any page. Use an additional sheet of paper.

If  you  are  called  to  the  jury  box,  your  answers  to  this  questionnaire  become  a 
matter of public record, just as if you had answered the questions aloud in the 
courtroom.

If you have trouble reading, understanding, or filling out this form, please let the 
court clerk know.

PLEASE  REMEMBER  THAT  YOU  ARE  ANSWERING  THESE  QUESTIONS 
UNDER  PENALTY  OF  PERJURY.  YOUR  ANSWERS  MUST  BE  TRUE  AND 
COMPLETE. THANK YOU FOR YOUR HELP IN SELECTING A FAIR JURY.

Form Approved for Optional Use  
Judicial Council of California 
JURY-001 [Rev. September 1, 2018] 

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JUROR QUESTIONNAIRE 
FOR CIVIL CASES

General Questions  
PLEASE PRINT ALL ANSWERS LEGIBLY

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FULL NAME:

1.1

DATE AND PLACE OF BIRTH:

1.2

AREA, NEIGHBORHOOD, OR COMMUNITY IN THIS COUNTY WHERE YOU CURRENTLY LIVE (DO NOT GIVE YOUR 
ADDRESS):

HOUSE

APARTMENT

OWN

RENT

1.3

AREA, NEIGHBORHOOD, OR COMMUNITY WHERE YOU HAVE LIVED IN THE PAST 10 YEARS (AND DATES):

1.4

WHAT IS THE HIGHEST LEVEL OF EDUCATION YOU COMPLETED?

GRADE SCHOOL OR LESS

SOME HIGH SCHOOL

HIGH SCHOOL GRADUATE

OTHER (PLEASE EXPLAIN):

SOME COLLEGE

(MAJOR):

COLLEGE GRADUATE

POSTGRADUATE STUDY

(MAJOR):

(MAJOR):

(MAJOR):

TECHNICAL, VOCATIONAL, OR BUSINESS SCHOOL

1.5 IF YOU PLAN TO ATTEND OR ARE CURRENTLY ATTENDING SCHOOL, DESCRIBE:

1.6 IF YOU HAVE TAKEN ANY COURSES OR HAD ANY TRAINING IN MEDICINE OR OTHER HEALTH CARE FIELD,  

DESCRIBE:

Form Approved for Optional Use  
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JURY-001 [Rev. September 1, 2018] 

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1.7  

IF YOU HAVE TAKEN ANY COURSES OR HAD ANY TRAINING IN LAW OR A RELATED SUBJECT, DESCRIBE:

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1.8 

EDUCATIONAL BACKGROUND OF ANY OTHER ADULT WHO LIVES IN YOUR HOME, INCLUDING ANY DEGREES OR        
CERTIFICATES EARNED:

1.9 

YOUR PRESENT EMPLOYMENT STATUS (CHECK ALL THAT APPLY):

EMPLOYED FULL-TIME

RETIRED

UNEMPLOYED, LOOKING FOR WORK

EMPLOYED PART-TIME

STUDENT

UNEMPLOYED, NOT LOOKING FOR WORK

HOMEMAKER

1.10 

YOUR CURRENT OR MOST RECENT OCCUPATION:

1.11

NAME OF YOUR CURRENT OR MOST RECENT EMPLOYER OR, IF A STUDENT, YOUR SCHOOL:

1.12

WHAT ARE YOUR SPECIFIC DUTIES AND RESPONSIBILITIES ON THE JOB?

1.13

DOES YOUR JOB INVOLVE SUPERVISING OTHER PEOPLE?
IF YES, APPROXIMATELY HOW MANY?

YES

NO

1.14 

ARE YOU INVOLVED IN THE HIRING OR FIRING OF OTHER EMPLOYEES?

YES

NO

1.15 

ARE YOU INVOLVED IN EVALUATING THE JOB PERFORMANCE OF OTHER EMPLOYEES?

YES

NO

1.16 

ALL OTHER EMPLOYMENT YOU HAVE HAD (AND FOR HOW LONG):

1.17

ALL FULL-TIME EMPLOYMENT OF YOUR SPOUSE OR ANY PERSON WITH WHOM YOU HAVE A SIGNIFICANT  
PERSONAL RELATIONSHIP (AND FOR HOW LONG):

1.18

WHAT ARE/WERE THE OCCUPATIONS OF YOUR PARENTS? (IF RETIRED, WHAT DID THEY DO BEFORE?)

MOTHER:

FATHER:

Form Approved for Optional Use  
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JURY-001 [Rev. September 1, 2018] 

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1.19 

IF YOU HAVE CHILDREN, PLEASE LIST (INCLUDING ANY CHILDREN WHO DO NOT CURRENTLY LIVE WITH YOU):

SEX

AGE

DOES CHILD LIVE 
WITH YOU?

EDUCATION

OCCUPATION

JURY-001

1.20

IF YOU OR YOUR CURRENT SPOUSE OR PERSON WITH WHOM YOU HAVE A SIGNIFICANT PERSONAL             
RELATIONSHIP HAS EVER SERVED IN THE MILITARY, PLEASE LIST FOR EACH THE BRANCH OF SERVICE AND DATES 
OF SERVICE:

1.21

WHAT SOCIAL, CIVIC, PROFESSIONAL, TRADE, OR OTHER ORGANIZATIONS ARE YOU AFFILIATED WITH?

1.22

DESCRIBE ANY OFFICES YOU HAVE HELD IN ORGANIZATIONS LISTED ABOVE:

1.23

DO YOU KNOW ANYONE ON THIS JURY PANEL?

1.24

ON HOW MANY CASES HAVE YOU SERVED ON A JURY?

WHERE DID YOU SERVE ON A JURY?

WHAT KINDS OF CASES DID YOU HEAR WHILE SERVING ON A JURY?

IN HOW MANY OF THOSE CASES DID THE JURY REACH A VERDICT?

IN HOW MANY OF THOSE CASES DID YOU SERVE AS THE JURY FOREPERSON?

WAS YOUR JURY SERVICE A POSITIVE OR NEGATIVE EXPERIENCE?

1.25

IF YOU HAVE EVER BEEN TO COURT FOR ANY OTHER REASON (EXCLUDING DIVORCE), EXPLAIN:

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1.26

IF YOU PERSONALLY KNOW ANY JUDGES OR ATTORNEYS OR COURT PERSONNEL, WHAT ARE THEIR NAMES AND 
RELATIONSHIP TO YOU?

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1.27 

DESCRIBE ANY PROBLEMS (VISION, HEARING, OR OTHER MEDICAL PROBLEMS) THAT MAY AFFECT YOUR JURY  
SERVICE:

1.28

IF YOU OR ANYONE CLOSE TO YOU HAS EVER MADE ANY TYPE OF CLAIM FOR DAMAGES, EXPLAIN:

1.29

IF A CLAIM FOR MONEY DAMAGES HAS EVER BEEN MADE AGAINST YOU OR ANYONE CLOSE TO YOU, EXPLAIN THE 
CIRCUMSTANCES:

1.30

IF YOU OR ANYONE CLOSE TO YOU HAS EVER SUED OR BEEN SUED IN ANY TYPE OF LAWSUIT, EXPLAIN:

1.31

DO YOU FEEL THAT MONEY DAMAGES AWARDED IN LAWSUITS ARE (CHECK ONE):

EXCESSIVE

OCCASIONALLY TOO LOW

OFTEN TOO LARGE

OFTEN TOO LOW

ABOUT RIGHT

OTHER (SPECIFY):

1.32

IF YOU HAVE ANY ETHICAL, RELIGIOUS, POLITICAL, OR OTHER BELIEFS THAT MAY PREVENT YOU FROM SERVING 
AS A JUROR, EXPLAIN:

1.33

IF THERE IS ANY MATTER NOT COVERED BY THIS QUESTIONNAIRE THAT COULD AFFECT YOUR ABILITY TO BE A 
FAIR AND IMPARTIAL JUROR, EXPLAIN:

Form Approved for Optional Use  
Judicial Council of California 
JURY-001 [Rev. September 1, 2018] 

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JUROR QUESTIONNAIRE 
FOR CIVIL CASES

Personal Injury Supplement

JURY-001

FULL NAME:

2.1

IF YOU OR ANYONE CLOSE TO YOU HAS EVER BEEN INVOLVED IN AN ACCIDENT IN WHICH SOMEONE WAS  
INJURED, EXPLAIN:

2.2 PLACE A CHECK MARK ON THE APPROPRIATE LINE(S) IF YOU OR ANYONE CLOSE TO YOU HAS EVER BEEN  

EMPLOYED IN ANY CAPACITY BY ANY OF THE FOLLOWING TYPES OF BUSINESSES:

YOURSELF

OTHER PERSON

ANY COURT IN THE STATE OF CALIFORNIA 

ATTORNEY, LAW FIRM, OR LAW OFFICE

CLAIMS ADJUSTMENT, EVALUATION, REVIEW, SETTLEMENT, OR  INVESTIGATION

ACCIDENT INVESTIGATION OR LAW ENFORCEMENT 

DISABILITY, HEALTH, LIFE, CASUALTY, OR ACCIDENTAL INJURY BENEFITS OR 
PROGRAMS

ECONOMICS, ACTUARIAL, OR INVESTMENTS

HEALTH CARE DOCTOR, NURSING, HOSPITAL, DENTAL,  PHYSICAL THERAPY, 
PHARMACY, OR ANY RELATED FIELD

2.3

IF YOU CHECKED ANY LINE IN THE PREVIOUS QUESTION (2.2), PLEASE STATE THE RELATIONSHIP OF THAT  
PERSON TO YOU, THE TYPE AND DETAILS OF THAT EMPLOYMENT, AND THE YEARS OF THAT EMPLOYMENT:

2.4 DO YOU HAVE ANY BELIEFS AGAINST AWARDING DAMAGES FOR PERSONAL INJURY, PAIN, OR SUFFERING?

YES

NO

IF YES, EXPLAIN:

YES

NO

IF YES, EXPLAIN:

2.5

DO YOU OR ANY MEMBERS OF YOUR IMMEDIATE FAMILY OR HOUSEHOLD SEE A DOCTOR OR OTHER MEDICAL 
PRACTITIONER REGULARLY FOR ANY CONTINUING MEDICAL PROBLEM?

Form Approved for Optional Use  
Judicial Council of California 
JURY-001 [Rev. September 1, 2018] 

JUROR QUESTIONNAIRE FOR CIVIL CASES/Personal Injury Supplement

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JUROR QUESTIONNAIRE 
FOR CIVIL CASES

JURY-001

Verification

(TYPE OR PRINT NAME)

, DECLARE UNDER PENALTY OF PERJURY UNDER THE 

LAWS OF THE STATE OF CALIFORNIA THAT THE FOREGOING RESPONSES I HAVE GIVEN ON THIS JUROR 
QUESTIONNAIRE, AND ON ANY ATTACHED SHEETS, ARE TRUE AND CORRECT TO THE BEST OF MY  
KNOWLEDGE AND BELIEF.

I,

Date:

(SIGNATURE OF DECLARANT)

Form Approved for Optional Use  
Judicial Council of California 
JURY-001 [Rev. September 1, 2018] 

JUROR QUESTIONNAIRE FOR CIVIL CASES/Verification

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