COVID-19 Prescreening Questionnaire

PARTICIPANT INFORMATION

*All information is required.



PRESCREENING QUESTIONS

*All questions are required.
  1. Have you traveled outside of the United States within the last 14 days?


  2. Have you been diagnosed with, or had close contact with, anyone who has been diagnosed with COVID- 19 within the last 14 days?


  3. Because of COVID-19, have you been asked to self-quarantine by any doctor, hospital, or health agency within the last 14 days?


  4. Have you experienced any cold or flu-like symptoms in the last 14 days (including fever, cough, sore throat, respiratory illness, or difficulty breathing)?


  5. Would you like to be considered for excuse or deferral of service because you are over age 65, or a person of any age with an underlying medical condition that puts you at a higher risk of developing serious health complications from COVID-19?


  6. Would you like to be considered for excuse or deferral of service because you live with or provide direct care for a vulnerable person or do you work in the medical field?


  7. Would you like to be considered for excuse or deferral of service because you have children at home who require your direct supervision due to school and/or daycare closures? Note: Only answer YES if there is NO ONE else in the household who can provide care during your jury service.



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