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?*YesNoHave you returned to employment?*YesNoWhen did you return to employment?* Date Format: MM slash DD slash YYYY Do you expect to return to your employment?*YesNoWhen do you expect to return to employment?* Date Format: MM slash DD slash YYYY Have you and/or any member of your immediate household traveled outside of Ohio in the past two weeks?*YesNoDid you and/or the household member self-quarantine for 14 days upon your return to Ohio?*YesNoWhich 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?*YesNoWhen did the notification take place?* Date Format: MM slash DD slash YYYY Were you and/or the household member required to self-quarantine?*YesNoDid you and/or the household member self-quarantine for the required period?*YesNoHave 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?*YesNoPlease 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?YesNoPlease explain*Are you or any member of your immediate household 65 years of age or older?*YesNoAre you currently residing in a nursing home or long-term care facility?*YesNoBadge Number*Name This iframe contains the logic required to handle Ajax powered Gravity Forms. Categories Uncategorized Tags Share This Article:
