Our employees’ and jurors’ safety remain the Court’s overriding priority.  The Chief Judge is monitoring the COVID-19 Pandemic closely and will coordinate juror reporting based on current recommendations from the Centers for Disease Control and local and national health authorities.

To prevent the spread of COVID-19 and reduce its potential risk, we are using this screening questionnaire.  Your answers are important to help us take precautionary measures to protect you and everyone in our courthouse.  Please complete and submit the questionnaire below.  Please note that we will not share your answers to this questionnaire with anyone outside the Court.  Thank you for your time.

First Name
Last Name
Participant No.
Phone No.
1. Have you traveled outside the United States within the last 14 days? Yes No
2. Have you been diagnosed with or had close contact with anyone diagnosed with COVID-19 within the last 14 days? Yes No
3. Because of COVID-19, have you been asked or had close contact with anyone asked to self-quarantine by any doctor, hospital, or health agency within the last 14 days? Yes No
4. Have you experienced any cold or flu-like symptoms in the last 14 days (including fever, cough, sore throat, respiratory illness, vomiting, or difficulty breathing)? Yes No
5. Would you like to be considered for excuse from or deferral of jury service because you are over age 65 or a person of any age with an underlying medical condition or are taking a medication that puts you at a higher risk of developing serious health complications from COVID-19? (See description list on reverse of the paper) Yes No
6. Would you like to be considered for excuse from or deferral of jury service because you live with or provide direct care for a vulnerable person (see description list on reverse of this paper), or do you work in the medical or first responder fields? Yes No
7. Would you like to be considered for excuse from or deferral of jury service because you have children at home or a vulnerable person to care for who require your direct supervision due to school, daycare or in-home caregiver closures? Note: Only answer YES if NO ONE else your household to provide care during your jury service. Yes No
8. In light of COVID-19 and the ongoing pandemic, for your safety, the court will mandate adherence to proper social distancing and may require masks be worn by all court staff and participants, including jurors. How comfortable are you traveling to the courthouse and potentially serving as a juror at this time?
Comfortable Somewhat Comfortable Somewhat Uncomfortable Not Comfortable
If you answer "Yes" to any of the above questions, the court's jury staff will contact you regarding your jury service status. If you have any questions, please submit them via email to jury@caed.uscourts.gov.
I declare under penalty of perjury that all answers are true to the best of my knowledge and belief.
 
Please enter your name below to sign this questionnaire electronically.
Signature: Date: