2. First Name*
3. Last Name*
5. Address1*
7. City
8. State
9. Zip
11. Phone number*
12. Alternate phone number
14. Email Address*
16. Date you are summoned for
    Date you are summoned for
18. Covid-19 Pre-Screening Questionnaire

    Within the last 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
    2. Loss of taste 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. Tested positive for Covid-19
    6. Had recent known exposure to Covid-19
    7. NONE of these conditions apply
20. 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; or
    2. I certify that I meet the above-described conditions and I am requesting to postpone my jury service.
22. Additional comments or information
Leave This Blank:


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

    This field is not part of the form submission.

26. Submit

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