ADDITIONAL JUROR QUESTIONNAIRE REGARDING COVID-19 Name: * Please enter your 9 Digit Participant Number: * To prevent the spread of COVID-19 and to reduce the potential risk of COVID-19 exposure to the court’s staff, jurors, and others appearing before the court, please complete this juror questionnaire and click Submit at the bottom of the page. 1. Have you or a member of your household been exposed recently to COVID-19 or someone who has tested positive for COVID-19? * Yes No 2. If yes, approximate date of exposure: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20222023202420252026 3. Have you or a member of your household tested positive for COVID-19 within the last two weeks? * Yes No 4. If yes, date of positive test: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20222023202420252026 5. Are you currently experiencing any cold or flu-like symptoms in the last 14 days (including fever, chills, cough, sore throat, new loss of sense of taste or smell, muscle pain, respiratory illness, shortness of breath or difficulty breathing)? * Yes No 6. Have you been vaccinated against COVID-19? Yes No 7. If yes, 1 shot or 2 shots or booster? One Two Booster 8. If you have any concerns related to COVID-19, please explain: 9. Please provide a telephone number in case the court needs to contact you * I declare under penalty of perjury that the foregoing is true and correct. Signature of Juror * Date: * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20222023202420252026 CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
