Superior Court Juror Questionnaire

Juror Questionnaire Form

Date to appear:

Open the calendar popup.

Summons Number:

Juror ID:

First Name:

Middle Name:

Last Name:

Street Address:

City:

State:

Zip Code:

Are you a U.S. Citizen?

YesNo

Have you been convicted of a felony?

YesNo

How long have you lived in this county?

E-Mail Address: Cell Phone:		Business Phone:
Place of Birth:		Age:
Marital Status: MarriedWidow(er) SingleSeparated		Name of Spouse/Partner: Age of Spouse/Partner: Number of children:
What is your type of work? Arrest powers?		Number of years worked at current employer?
What is your spouse/partner's type of work?		Number of years spouse/partner worked at current employer?

Your present employer:

Have you or a member of your immediate family been a party to a law suit?

YesNo

If Yes, when and in what court?

Spouse/Partner's employer:

Has a claim of personal injury ever been made against you?

YesNo

Are you related by blood or marriage to any person in Law enforcement?

YesNo

Have you ever served as a juror?
YesNo If yes, what type of case? CriminalCivilBoth

Have you ever been a victim of a crime?

YesNo

If Yes, when and what type of crime?

Name of Insurance Carriers:

Auto Insurance Carrier:

Homeowner's Insurance Carrier:

Health Insurance Carrier:

Additional Covid-19 Questions:

Have you been exposed to COVID-19?

YesNo
If yes, approximate date of exposure:

Open the calendar popup.

Have you tested positive for COVID-19?

YesNo
If yes, approximate date of exposure:

Open the calendar popup.

Are you currently experiencing any symptoms of COVID-19 (including fever, cough, sore throat, respiratory illness, or difficulty breathing) and been told to quarantine?

YesNo If yes, approximate date instructed to quarantine:

Open the calendar popup.

Are you a vulnerable person as defined by CDC guidelines? YesNo

If yes, please explain:

Are you over age 60, or a person of any age with an underlying medical condition that puts you at a higher risk of developing serious health complications from COVID-19? YesNo
If yes, please explain:

Do you live with or provide direct care for a vulnerable person?

YesNo
If yes, please explain:

Do you have children at home who require your direct supervision due to school and/or daycare closings? Note: Only answer YES if there is NO ONE else in the household who can provide care during your jury service.

YesNo
If yes, please explain:

Traveled internationally in the last 14-days?

YesNo
If yes, Location(s):

Traveled outside of Georgia in the last 14-days?

YesNo
If yes, Location(s):

Traveled on a river boat or cruise ship in the last 14-days?

YesNo
If yes, Location(s):

Additional Technology Questions:

You may be asked to serve as a juror-from-home using a video conference platform. Please complete the questions below to indicate your eligibility.

Do you have EACH of the following:

A private and quiet space? YesNo	Access to a reliable internet connection? YesNo	Access to a tablet,smart phone, or desktop or laptop computer with a camera? YesNo
The physical ability to watch and listen to court proceedings using a computer or phone? YesNo	The general ability to watch and listen to court proceedings without interruption or distraction? YesNo	Experience with video conferencing platforms such as Zoom? YesNo

Website Issues Email: webmaster@co.henry.ga.us
Henry County Administration Building
Phone: 770.288.6000
140 Henry Parkway
McDonough, GA 30253

**Please see each individual department page for contact and staff information**


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