W. Va. Code § 52-1-5a – Jury qualification form; contents; procedure for use; penalties.

(a) Not less than twenty days before the date for which persons are to report for jury duty, the clerk may, if directed by the court, serve by first-class mail, upon each person listed on the master list, a juror qualification form accompanied by instructions necessary for its completion: Provided, That the clerk may, if directed by the court, mail the juror qualification form to only those prospective jurors drawn for jury service under the provisions of section seven of this article. Each prospective juror shall be directed to complete the form and return it by mail to the clerk within ten days after its receipt. The juror qualification form is subject to approval by the circuit court as to matters of form and shall elicit the following information concerning the prospective juror:
1. (1) The juror's name, sex, race, age and marital status;
2. (2) The juror's level of educational attainment, occupation and place of employment;
3. (3) If married, the name of the juror's spouse and the occupation and place of employment of the spouse;
4. (4) The juror's residence address and the juror's mailing address if different from the residence address;
5. (5) The number of children which the juror has and their ages;
6. (6) Whether the juror is a citizen of the United States and a resident of the county;
7. (7) Whether the juror is able to read, speak and understand the English language;
8. (8) Whether the juror has any physical or mental disability substantially impairing the capacity to render satisfactory jury service: Provided, That a juror with a physical disability, who can with reasonable accommodation render competent service, is eligible for service;
9. (9) Whether the juror has, within the preceding two years, been summoned to serve as a petit juror, grand juror or magistrate court juror, and has actually attended sessions of the magistrate or circuit court and been reimbursed for his or her expenses as a juror;
10. (10) Whether the juror has lost the right to vote because of a criminal conviction; and
11. (11) Whether the juror has been convicted of perjury, false swearing or any crime punishable by imprisonment in excess of one year under the applicable law of this state, another state or the United States.
  The juror qualification form may also request information concerning the prospective juror's religious preferences and organizational affiliations, except that the form and the accompanying instructions shall clearly inform the juror that this information need not be provided if the juror declines to answer such inquiries.
(b) The juror qualification form shall contain the prospective juror's declaration that the responses are true to the best of the prospective juror's knowledge and an acknowledgment that a willful misrepresentation of a material fact may be punished by a fine of not more than $500 or imprisonment for not more than thirty days, or both fine and imprisonment. Notarization of the juror qualification form shall not be required. If the prospective juror is unable to fill out the form, another person may assist the prospective juror in the preparation of the form and indicate that such person has done so and the reason therefor. If an omission, ambiguity or error appear in a returned form, the clerk shall again send the form with instructions to the prospective juror to make the necessary addition, clarification or correction and to return the form to the clerk within ten days after its second receipt.
(c) Any prospective juror who fails to return a completed juror qualification form as instructed shall be directed by the clerk to appear forthwith before the clerk to fill out the juror qualification form. At the time of the prospective juror's appearance for jury service, or at the time of any interview before the court or clerk, any prospective juror may be required to fill out another juror qualification form in the presence of the court or clerk. At that time the prospective juror may be questioned with regard to the responses to questions contained on the form and the grounds for the prospective juror's excuse or disqualification. Any information thus acquired by the court or clerk shall be noted on the juror qualification form.
(d) Any person who willfully misrepresents a material fact on a juror qualification form or during any interview described in subsection (c) of this section, for the purpose of avoiding or securing service as a juror, is guilty of a misdemeanor and, upon conviction thereof, shall be fined not more than $500 or imprisoned not more than thirty days, or both fined and imprisoned.
(e) Upon the clerk's receipt of the juror qualification questionnaires of persons selected as prospective petit jurors, he or she shall make the questionnaires of the persons so selected available, upon request, to counsel of record in the trial or trials for which the persons have been selected as prospective jurors: Provided, That upon the conclusion of the trial the juror qualification forms for persons serving on a particular trial jury may only be released with the written permission of the judge who presided over the trial or his or her successor: Provided, however, That if the judge denies the request, the reasons for the denial must be in writing and be share with all parties in the case and the person making the request within thirty days after filing the motion.