01/26/2021 COVID-19 Screening Questionnaire

1

Are you here because you were summoned for jury service?

YESNO

2

What is your name? * This field is required.If you were summoned for jury service, please list your name exactly as it appears on the summons.

Prefix

First Name

Middle Name

Last Name

3

Select the option that best describes your reason for visiting the court house today.* This field is required.

Attorney

Staff/Employee

Witness

Visitor

4

Jury Summons Number* This field is required.

Located on your Jury Summons

5

What time were your told to report for jury duty?* This field is required.

Minutes

6

I swear to answer the following questions truthfully and that my answers are under penalty of perjury. I also understand that if I knowingly provide false information I am subject to a fine between $100 and $1,000.* This field is required.

YESNO

7

In the past 30 days, have you or a member of your household tested positive for the coronavirus disease (COVID-19) ?* This field is required.

YESNO

8

Do you or a member of your household have have a pending test result for the coronavirus disease (COVID-19)* This field is required.

YESNO

9

In the past 14 days, have you or a member of your household had in-person close contact with a person diagnosed with coronavirus disease (COVID-19)?* This field is required.

YESNO