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COVID-19 Health Questionnaire

Your participation in jury service is greatly appreciated and extremely important for the court to continue essential judicial proceedings. To prevent the spread of COVID-19 and reduce the potential risk of exposure, you are required to complete this questionnaire. Your completion of this questionnaire is vital to help us take precautionary measures to minimize risk to you and all who enter the courthouse. Please complete the questionnaire within 24 to 48 hours prior to coming to the courthouse and bring it with you to check-in.


• A fever • New or worsening cough • Shortness of breath or trouble breathing • New loss of ability to taste or smell • Nausea, vomiting or diarrhea
(Note: Information from the CDC regarding groups at higher risk for severe illness from COVID-19 can be found at

Answers to questions above are true to the best of my knowledge. Entering your name in the signature line below qualifies as your signature.