1. Have you been diagnosed with, or had close contact with, anyone who has been diagnosed with COVID-19 within the last 14 days? * Yes No 2. Have you experienced any cold or flu-like symptoms in the last 14 days (including fever or chills, new loss of taste or smell, cough, shortness of breath or difficulty breathing, diarrhea, nausea or vomiting)? * Yes No 3. Please check one: * I do not feel comfortable coming to the courthouse for jury service, because of COVID-19 I do feel comfortable coming to the courthouse for jury service. 4. I WISH TO POSTPONE my jury service because of effects of the COVID-19 pandemic (please check all that apply and explain): I or someone in my household is at high risk for complications from contracting COVID-19 disease because of age, medical condition, or other characteristic. I have childcare or eldercare issues that will make it difficult for me to serve. I am a healthcare worker directly involved with the treatment of the COVID-19 disease, or I work in another field that puts me in direct contact with people who have been diagnosed with COVID-19. Please explain below any answer above for postponement of jury service because of the COVID-19 pandemic: * 5. Is there anything about the COVID-19 pandemic and the public health orders, including the orders of this Court, such as wearing a protective face covering or social distancing, that would affect your ability to be a fair and impartial juror in this case? If yes, please explain: I declare under penalty of perjury that all answers are true to the best of my knowledge and belief. Signature * Date * Month MonthApr Day Day21 Year Year2021 Print Name * Participant Number (located on summons) *
