Kelly on Malpractice

JURY QUESTIONNAIRE Juror Number: ___________

PLEASE READ CAREFULLY:
In order to assist the Court and counsel with this case, please answer every question to ensure a fair trial. Answer to the best of your knowledge and ability and where there is space to write your answer it is important for you to do so. There are no “right” or “wrong” answers. Do not write on the back of any pages. Be assured that your answers are strictly confidential and will be seen only by the judge, the lawyers, and their assistants.

Please print neatly and clearly

1. Your Name: __________________________________________________________________
2. Area where you primarily grew up: ___________________________________________________________
3. City/town where you live and address: ________________________________________________________
4. How long have you lived in this community? ____________
5. Where did you live before this? ____ For how long?____________
6. Do you: ____ own? OR ____ rent?
7. With whom do you live, if anyone?
8. Educational Background: What is the highest grade level you have completed:
_____ less than 8th grade _____ technical, business or two year degree
_____ more than 8th grade _____ some college but no degree
but no high school degree _____ four year college degree in
_____ high school degree _____ post graduate work or degree in

9. Please list school & degrees you have from technical, vocational or colleges attended:
School Major/area of study Degree/certificate Date
________________________________________________________________________________________________________
________________________________________________________________________________________________________
_________________________________________________________________________________________________________

10. If still in school, list any extracurricular activities you are involved in: __________________
_____________________________________________________________________________________________________
11. What is your current job status? (Please check the most appropriate answer)
_____ working full time ______ unemployed _____ homemaker
_____ working part time ______ retired _____ full time student
_____ working more than one job ______ disability
12. What is your occupation and type of business? (If retired or unemployed, please state your former occupation) _____________________________________________________________________

13. What are/were your job responsibilities? ____________________________________________________
_________________________________________________________________________________________________________
14. Do you supervise the work of others in your line of work? 0 Yes 0 No
If yes, how many? _________________________
15. Please list your last two employers, prior to your current or retired from employer.
Name City, State Job Title
______________________________________________________________________________________________________ ______________________________________________________________________________________________________
16. Have you, any member of your family or a close friend ever been employed in or had experience or special training in any of the following areas? Yes No
Medical (doctor, nurse, therapist, medical lab, etc) 0 0
Mental Healthcare 0 0
Vocational Rehabilitation 0 0
Firearms 0 0
Legal/Law 0 0
Risk Management 0 0
Owning a business 0 0
Economics 0 0
If YES, list who, when, how long and type of job and/or training in the space below.
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
17. Marital status:
_____ Single and never married _____ Divorced
_____ Currently married for _____ # of years _____ Widowed

18. If married, please state number of years of spouse’s formal education: ____________
19. If married, how many times have you been married? ___________
20. If married, divorced, widowed, or have a significant other, what is/was the occupation of him/her? ________________________________________________________________________________________
a. Please give his/her employer: ______________________________________________________________
b. Please explain what his/her duties are/were: _____________________________________________

21. Do you have children or stepchildren, or are you a guardian to any children?
0 Yes 0 No
If yes, list the following:
Age Where they live Occupation, if Adult Child
a. ______________________________________________________________________________________________
b. _____________________________________________________________________________________________
c. _______________________________________________________________________________________________
d. _______________________________________________________________________________________________
e. _______________________________________________________________________________________________

22. Do you belong to any social clubs, professional organizations, fraternities/sororities or religious organizations? 0 Yes 0 No
If YES, please list below organization(s) and your involvement with them; like, hold any offices, how often you meet, sing in a choir, etc.

____________________________________________________________________________________________________

_____________________________________________________________________________________________________

23. Have you or anyone in your household ever written a letter to the editor of a publication, newspaper, radio station, TV station or a public figure? 0 Yes 0 No
If yes, please state the topic(s): ____________________________________________________________________

24. Do you consider yourself to be a: 0 Liberal 0 Moderate 0 Conservative

25. Do you, your spouse, or anyone in your immediate family use a computer either at home or work to look up information about medical topics or healthcare?

0 Yes 0 No If YES, please state which websites you visit for this research?

____________________________________________________________________________________________________

____________________________________________________________________________________________________
26. Please tell us your opinions about the debate that is currently being discussed in our country about the healthcare system.
_______________________________________________________________________________________________________

_______________________________________________________________________________________________________
27. Have you, a family member or close friend ever been employed by, owned stock in, done business with, or been associated with any of the following?

Johnson Medical Center 0 Yes 0 No

Tri-Star Hospitals (formerly HCA) 0 Yes 0 No

Charter / Lakeside 0 Yes 0 No

If yes to any of the above, please explain the nature of your involvement; business
interest and/or association:
_________________________________________________________________________________________________

__________________________________________________________________________________________________
28. Have you, a family member or close friend ever been a patient at Centennial Medical Center or Parthenon Pavilion? 0 Yes 0 No
If YES, please list who the patient(s) were, why he or she went there for treatment.
_______________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
If YES, was/were the patient(s) satisfied with the treatment received?
0 Yes 0 No If NO, please explain: __________________________________________________
______________________________________________________________________________________________________
29. Have you, a family member or close friend, had any experience with mental illness and/or depression? 0 Yes 0 No
If YES, please explain:
You—Mental Illness and/or Depression: ______________________________________________
_______________________________________________________________________________________________

Other Person—and how you know them—Mental Illness and/or Depression:
_________________________________________________________________________________________________

_________________________________________________________________________________________________

30. If YES, you or someone close to you has experienced mental illness and/or
depression, did you or they get treatment? 0 Yes 0 No

a. If YES, please explain who and type of treatment:
__________________________________________________________________________________________
__________________________________________________________________________________________
b. If YES, you or someone close to you got treatment for mental illness and/or depression, were you/they satisfied with the treatment? 0 Yes 0 No
If no, please explain: __________________________________________________________________
_____________________________________________________________________________________________
31. Do you know anyone who has committed suicide, attempted suicide, or considered suicide? 0 Yes 0 No
If YES, please explain how you know this person and circumstances of the situation:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
a. Was there a lawsuit involved? 0 Yes 0 No
b. If YES, was it settled to the family’s satisfaction? 0 Yes 0 No
c. If NO, please explain: __________________________________________________________________
____________________________________________________________________________________________
32. Have you, a family member or close friend ever sought mental health counseling or visited with a therapist of any kind? 0 Yes 0 No
If yes, please explain: ___________________________________________________________________________ ______________________________________________________________________________________________________
33. In general, do you have any negative feelings or opinions about patients who bring medical malpractice lawsuits against healthcare providers? 0 Yes 0 No
If YES, please explain: _____________________________________________________________________________

________________________________________________________________________________________________________

34. In general, do you have any negative feelings or opinions about individuals employed in the mental healthcare profession (Psychiatrist, Psychologist, Social Worker, etc.)?
0 Yes 0 No
If YES, please explain __________________________________________________________________________
_____________________________________________________________________________________________________
35. Have you had any bad experiences with doctors, nurses, hospitals or other healthcare providers? 0 Yes 0 No

If YES, please explain: ___________________________________________________________________________

______________________________________________________________________________________________________
36. Do you have any experience or knowledge about mental illness or suicide which would affect your ability to serve as a juror in this case? 0 Yes 0 No

IF YES, please explain: _____________________________________________________________________________________________________

37. Do you own a handgun? 0 Yes 0 No

If yes, do you keep it in your house? 0 Yes 0 No

If yes, where in the house do you keep your gun? ____________________________________________

38. Have you or anyone in your household ever sued a doctor, hospital or healthcare
provider in a medical malpractice case? 0 Yes 0 No

If YES, was the case settled to your satisfaction? 0 Yes 0 No

39. Do you feel this is the type of case that you could sit in judgment and be a fair
and impartial juror to both sides? 0 Yes 0 No

40. Have you or any member of your household ever sued somebody for money in a court of law? 0 Yes 0 No

a. If YES, how many times have you sued someone? ___________________

b. What was/were the lawsuits about? ____________________________________________________

c. Was the case resolved to your/their satisfaction? 0 Yes 0 No

If NO, please explain: ________________________________________________________________

41. Have you or another member of your household ever been sued by somebody?

0 Yes 0 No IF YES, how many times? ___________________

a. What was/were lawsuit(s) about? _________________________________________________

_______________________________________________________________________________________
b. Was the case resolved to your/their satisfaction? 0 Yes 0 No

If NO, please explain: ________________________________________________________________

42. Have you ever served in the Military? 0 Yes 0 No

If YES, When: ________________ What branch: ___________________________________

Where did you serve: _______________________________________________________________________

What rank were you when you left the military: _______________________________________

43. Have you ever served on a jury before? 0 Yes 0 No

IF YES, was your jury service a Civil Case ____________ Or Criminal Case ___________________

What was the nature of the case? _______________________________________________________________

Where you satisfied with the verdict? 0 Yes 0 No

44. Would it make you uncomfortable to discuss or decide a case involving a 24 year old man who committed suicide? 0 Yes 0 No

If YES, please explain: _________________________________________________________________________

_____________________________________________________________________________________________________

45. Is there anything else you believe we should know about you that would affect your ability to serve as a juror in a case involving suicide where the patient’s family brings a medical malpractice claim? 0 Yes 0 No

IF YES, please explain: ____________________________________________________________________

_______________________________________________________________________________________________

46. I swear or affirm that the answers to these questions are true and correct to the best of my knowledge and belief.

____________________________ ___________________________
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