New York Codes, Rules and Regulations
Title 22 - JUDICIARY
Subtitle D - Forms
Chapter VI - Forms For Use In Courts Exercising Criminal Jurisdiction
Form 10 - Juror questionnaire
Sec. 270.15 C.P.L. FORM 10
YOU HAVE BEEN SELECTED TO SERVE AS A PROSPECTIVE JUROR. THIS QUESTIONNAIRE IS DESIGNED TO ASSIST COUNSEL AND THE COURT IN SELECTING FAIR AND IMPARTIAL JURORS. PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS ON THE FORM: HOWEVER, IF THERE IS INFORMATION THAT YOU WOULD PREFER TO KEEP CONFIDENTIAL, ASK TO SPEAK PRIVATELY TO THE JUDGE. THANK YOU FOR YOUR COOPERATION.
3. Place of birth____________
4. Current address____________
5. How long have you lived at your current address?____________
How long have you lived in this county?____________
6. Marital status____________
7. Years of education or highest degree obtained____________
9. Are you presently employed?________________________
10. Spouse's occupation____________
11. Is your spouse presently employed?____________
12. Number of ages of children____________
13. Are any of your children presently employed?____________
15. Have you ever served on a state or federal grand jury? ________ yes ________no
Have you ever served on a state or federal trial jury? ________ yes ________no
If yes, state type of case (criminal or civil) ____________
Did case reach a verdict? ________yes ________no
Most recent date of jury service________
16. Have you, any relative or close friend ever been any of the following:
a. The victim of a crime ________yes ________no
b. Witness to a crime ________yes ________no
c. Accused of a crime ________yes ________no
d. Convicted of a crime ________yes ________no
e. Party to a civil case ________yes ________no
17. Have you, any relative or close friend ever been employed by any law enforcement agency or criminal justice agency?
18. Do you have any mental or physical condition that would prevent you from serving as a juror?
19. Do you have any difficulty reading, understanding or speaking the English language? ____________
20. There is a possibility you may be required to stay overnight in a hotel during deliberations. Is there any reason why you feel you could not stay overnight if required and if you are given a day's advance notice? ____________
If after completing this questionnaire you feel you should not sit on this case for any other reason, please bring it to the judge's attention when your name is called.
I AFFIRM THAT THE STATEMENTS MADE ON THIS QUESTIONNAIRE ARE TRUE AND I UNDERSTAND THAT ANY FALSE STATEMENTS MADE ON THIS QUESTIONNAIRE ARE PUNISHABLE UNDER ARTICLE 210 OF THE PENAL LAW.
Signature of Prospective Juror