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2. First Name*
3. Last Name*
5. Address*
7. City*
8. State*
9. Zip Code*
11. Phone Number*
12. Alternate Phone Number
14. Email Address*
15. Date You Are Summoned For:*
    Date You Are Summoned For:
17. COVID-19 Pre-Screening Questionnaire

    Within the 14 days, have you experienced any of the following symptoms that cannot be attributed to another health condition (check all that apply):

    1. Fever above 100.0 degrees
    2. Loss of taste and/or smell
    3. Cough
    4. Nausea or vomiting
    5. Headache
    6. Shortness of breath/difficulty breathing
    7. Congestion/runny nose

    1. Chills
    2. Muscle pain or body aches
    3. Sore throat
    4. Diarrhea
    5. Texted positive for COVID-19
    6. NONE of these conditions apply
19. COVID-19 Related Excuse or Postponement

    If you are age 65 or older, or an individual with a serious underlying health condition, such as chronic lung disease, obesity, asthma, high blood pressure, diabetes, or those whose immune systems are compromised, such as by chemotherapy, or you have a particular vulnerability to COVID-19 and wish to be excused from jury service or request to postpone jury service please check the appropriate box below:

    1. I certify that I meet the above-described conditions and I am requesting to be excused from jury service.
    2. I certify that I meet the above-described conditions and I am requesting to postpone my jury service.
21. Additional Comments or Information
Leave This Blank:


23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit

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