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. Name * 1. Are you experiencing any of the following symptoms that are not attributable to another known condition? * • A fever • New or worsening cough • Shortness of breath or trouble breathing • New loss of ability to taste or smell • Nausea, vomiting or diarrhea Yes No You answered yes, please explain: * 2. In the last 14 days, have you been diagnosed with, or been in close contact with any person who has been diagnosed with, COVID-19? (Note: Close contact is defined by the CDC as having been within 6 feet of an individual for at least 15 minutes.) * Yes No You answered yes, please explain: * 3. In the last 14 days, have you been asked to self-quarantine, or cared for someone who was asked to self-quarantine, by any doctor or other medical health provider, hospital, or government agency? * Yes No You answered yes, please explain, including the date you have been advised to stop the self-quarantine: * 4. Do you feel that you, or a person that you live with or care for, are at high risk of becoming severely ill or developing serious health complications if infected with the COVID-19 virus, and don’t believe that you could serve? * (Note: Information from the CDC regarding groups at higher risk for severe illness from COVID-19 can be found at https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html) Yes No You answered yes, please explain: * Answers to questions above are true to the best of my knowledge. Entering your name in the signature line below qualifies as your signature. Signature * Date * Year Year202420252026 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031
