August 24, 2020 Juror letter with questionnaire View the Juror Letter Juror Questionnaire If you wish to be excused you must submit a WRITTEN request to the Jury Office.What is your occupation?* Were you, at any time, laid off from employment or otherwise prohibited from working as a result of the COVID-19 pandemic?* Yes No Have you returned to employment?* Yes No When did you return to employment?* MM slash DD slash YYYY Do you expect to return to your employment?* Yes No When do you expect to return to employment?* MM slash DD slash YYYY Have you and/or any member of your immediate household traveled outside of Ohio in the past two weeks?* Yes No Did you and/or the household member self-quarantine for 14 days upon your return to Ohio?* Yes No Which mode of transportation did you use?* Which state(s) did you travel through?*Have you or any member of your immediate household been notified by any health department that you and/or the household member have been in contact with an individual who tested positive for the COVID-19 virus?* Yes No When did the notification take place?* MM slash DD slash YYYY Were you and/or the household member required to self-quarantine?* Yes No Did you and/or the household member self-quarantine for the required period?* Yes No Have you or any member of your immediate household test positive for the COVID-19 virus and/or have any test results pending regarding the COVID-19 virus?* Yes No Please explain and provide date(s) or test(s)*Do you or any member of your immediate household have any of the following conditions:*chronic lung disease, moderate-severe asthma, serious heart condition, severe obesity, diabetes, chronic kidney disease or undergoing dialysis, liver disease, pregnant or breastfeeding? Yes No Please explain*Are you or any member of your immediate household 65 years of age or older?* Yes No Are you currently residing in a nursing home or long-term care facility?* Yes No Badge Number* Name Categories Uncategorized Tags Share This Article:
