You have been summoned by this Court for jury selection. The case for which you have been summoned for jury selection is a criminal case entitled United States of America v. Michael Arnold and Jeffrey Herholz. Mr. Arnold and Mr. Herholz are each charged by indictment with one count of conspiring to distribute controlled substances outside the scope of professional practice and not for a legitimate medical purpose. Mr. Arnold is charged separately with four individual counts of distributing controlled substances outside the scope of professional practice and not for a legitimate medical purpose. Mr. Arnold and Mr. Herholz are also charged with one count of conspiring to transfer funds into the United States with the intent to promote a specified unlawful activity. Mr. Arnold and Mr. Herholz have pled not guilty to all charges alleged in the indictment.
As part of the jury selection process, each of you must complete this juror questionnaire. The questions on this form are asked to assist the Court and the attorneys in the jury selection process for this trial. This questionnaire is designed to obtain information about your background as it relates to your possible service as a fair and impartial juror in this case. Its use will avoid the necessity of asking each prospective juror every one of these questions in open Court.
Unless the question states otherwise, the fact that a particular question is asked does not imply that the subject matter of the question is an issue in this case. As you read the questions, you are not to draw any inferences about the issues that must be decided in this case. The questions are not meant to invade your privacy but to help select a fair and impartial jury for this case. If there is any reason why you might not be able to give both sides a fair trial in this case, it is important to say so. Please answer each question as fully as you can. Your complete honesty is essential. Do not leave any questions blank. If a question does not apply to you in any way, write "N/A" (for "not applicable"), rather than leaving the form blank. If you do not understand the question, please write that in the space for the answer.
If you feel the answer is too personal, please say so in the space provided. You will have the opportunity to discuss your answer privately. If you do not understand a question, need more space for your response, or wish to make further comments about any question, please use the extra sheets attached at the end of the questionnaire. If you use the explanation sheets, please make sure to indicate which numbered question you are answering. DO NOT WRITE ON THE BACK ON ANY PAGE.
You are instructed not to discuss this case or questionnaire with anyone, including your family or fellow jurors. It is important that your answers be yours and yours alone. Your answers are confidential. They will be reviewed by the judge and the lawyers in this case. Following jury selection, the original questionnaire will be kept under seal and will be disclosed, if at all, with names and other identifying information removed.
Please print your name on the cover page and, upon completion, sign your name on the last page where indicated. If possible print your answers and use ink only. You are expected to sign your questionnaire, and your answers will be given the same effect as a statement given to the Court under oath.
Please fill out this form as completely as possible and print clearly. Since we want to make copies for the attorneys and the Court, do not write on the back of any page. If you need more room, continue at the bottom of the page. Thank you for your cooperation.
3. The city where you live:
5. Your marital status: (circle one) single married separated divorced widowed live with partner
6. Do you have any medical conditions that do not allow you to sit for several hours at a time?
7. Do you have any difficulty understanding English? _____ Yes _____ No
8. Do you have any difficulty seeing which might prevent you from seeing what is occurring in the courtroom, such as observing witnesses or viewing evidence? _____ Yes _____ No If yes, please explain what that condition is:
9. Do you have any difficulty hearing that might prevent you from hearing what is said in the courtroom from the witnesses, lawyers, or judge? _____ Yes _____ No If yes, please explain what that condition is:
10. What is your occupation, and how long have you worked in it? (If you are retired, or unemployed please describe your main occupation when you were working).
11. Who is (or was) your employer? __________________
12. Please list all your employers during the past 10 years and your job ...