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2. Jury Service COVID-19 Pre-Screening Questionnaire

   As part of the court's ongoing measures to protect against the spread of COVID-19, please complete the following before reporting for Jury Service.

4. Date of Jury Service*
   Date of Jury Service
6. 1. Symptoms now or 10 days before the date of Jury Service:*

   Check any that apply to you or a member of your household

   1. Fever (Above 100.0)
   2. Loss of taste or smell
   3. Cough
   4. Nausea or Vomiting
   5. Headache

   1. Shortness of Breath/Difficulty Breathing
   2. Diarrhea
   3. Chills
   4. Muscle Pain or Body Aches

   1. Sore Throat
   2. Fatigue
   3. Congestion or Runny Nose
   4. I certify that NONE of the symptoms above have been experienced by me or a member of my household between now and 10 days before reporting to jury service

8. If you are experiencing any of the above symptoms, call Abilene Municipal Court at (325) 676-6333 before reporting to Jury Service.

10. 2. Contact History*

    Check any that apply to you or a member of your household

    1. I have been diagnosed with COVID-19 within the past 10 days
    2. I or a member of my household has been in close contact with someone exposed to or infected with COVID-19 in the last 14 days
    3. I or a member of my household are currently on a watch list or self-quarantining because of possible COVID-19 exposure
    4. NONE of the above apply

12. If any of the above apply, call Abilene Municipal Court at (325) 676-6333 before reporting to Jury Service.

14. 3. COVID-19 Related Excuse or Postponement

    Individuals who are over age 65 and individuals with serious underlying health conditions, such as high blood pressure, chronic lung disease, diabetes, obesity, asthma, and those whose immune systems are compromised, such as by chemotherapy for cancer or other conditions requiring such therapy, are considered to be vulnerable populations and may request to postpone or be excused from jury service at this time. If you wish to be excused or request that your jury service be postponed, check the box below.

    1. I certify that I meet the above-described conditions and I am requesting to be excused from jury service or desire to have my service date postponed because of those conditions.

16. If you are requesting to be excused or your service date be postponed due to a COVID-19 related reason, call Abilene Municipal Court at (325) 676-6333 before reporting to Jury Service.

18. 4. Face Coverings

    Prospective jurors are encouraged but not required to wear a face covering while they are in the courthouse. Individuals are encouraged to bring a cloth face covering with them.

    I certify the above is true and correct:

20. Signature*
21. Today's Date*
    Today's Date
Leave This Blank:


23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit

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