2. DEAR PROSPECTIVE JUROR

   As part of the court's measures to protect against the spread of the COVID-19 disease, we ask that you complete and submit this questionnaire before reporting for jury service.

4. SYMPTOMS: check any that apply to YOU or A MEMBER OF YOUR HOUSEHOLD*

   1. Fever (100.0° F)
   2. Loss of taste or smell
   3. Cough
   4. Nausea or vomiting
   5. Headache
   6. Shortness of breath/Difficulty breathing
   7. Diarrhea

   1. Chills
   2. Muscle pain or body aches
   3. Sore throat
   4. Fatigue
   5. Congestion or runny nose
   6. I certify that NONE of the symptoms above have been experienced by me or a member of my household within the last 10 days.

   
   

   
   

   
   

   
   

   
   

   
   

   IF YOU ARE EXPERIENCING ANY OF THE ABOVE SYMPTOMS, CONTACT [email protected] TO BE EXCUSED FROM SERVICE.

6. 1. CONTACT HISTORY: check any that apply to YOU or A MEMBER OF YOUR HOUSEHOLD*

   1. I have or a member of my household has been diagnosed with COVID-19 within the past 10 days;
   2. I have or a member of my household has been in close contact with someone exposed to or infected with COVID-19 in the last 14 days;
   3. I am or a member of my household is currently on a watch list or self-quarantining because of possible COVID-19 exposure;
   4. NONE of the above apply.

   IF ANY OF THE ABOVE APPLY, CONTACT JURY SERVICES [email protected] TO BE EXCUSED FROM SERVICE.

8. 2.    COVID-19 RELATED EXCUSE OR POSTPONEMENT: Individuals who are over age 65 and individuals with serious underlying health conditions, such as high blood pressure, chronic lung disease, diabetes, obesity, asthma, and those whose immune system is compromised, such as by chemotherapy for cancer or other conditions requiring such therapy, are considered to be vulnerable populations and may request to postpone or be excused from jury service at this time. If you wish to be excused or request that your jury service be postponed, 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 desire to have my service date postponed because of those conditions.

   IF YOU ARE REQUESTING TO BE EXCUSED OR YOUR SERVICE DATE BE RESCHEDULED DUE TO A COVID-19 RELATED REASON, CONTACT [email protected].

10. 3.    FACE COVERINGS: Prospective jurors have the option to wear a face covering while they are in the courthouse. A disposable face mask will be provided upon request.

12. I certify the above is true and correct:
13. Phone
14. Date
    Date
16. COVID-19 SAFETY MEASURES
    • The judges and court staff are currently monitoring themselves prior to coming to work.
    • Judges or court staff who feel feverish or have measured temperatures above l00° F, or with new or worsening signs or symptoms of COVID-19 such as loss of taste or smell, cough, nausea or vomiting, headache, shortness of breath or difficulty breathing, diarrhea, chills, muscle pain or body aches, sore throat, fatigue, congestion or runny nose, or have knowingly had close contact with a person who is confirmed to have COVID-19 are not permitted to enter the building and are encouraged to seek medical advice.
    • Judges, court staff, and all other individuals have the option to wear face coverings while in the courtrooms. A disposable mask and/or face shield will be provided upon request.
    • Hand sanitizer dispensers have been placed throughout the court buildings.
    • Signage has been posted at the entrances of the court buildings. The signs have language asking individuals entering the court buildings if they are feeling feverish, have a cough, or shortness of breath to seek medical attention.
    • Staff who are screening individuals entering the courtrooms will be provided personal protective equipment, if desired.
    • Court building cleaning staff have been trained on proper cleaning techniques and provided appropriate personal protective equipment along with cleaning supplies shown to be effective with COVID-19.
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17. 1. Receive an email copy of this form.
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