City of Victoria Form Center

2. Dear Prospective Juror:
   As part of the court's ongoing measures to protect against the spread of COVID-19 disease, we ask that you complete the following before reporting for Jury Service on the date listed on the summons you received. Complete this questionnaire electronically through this form, or submit in in-person or through the mail before the date of your service listed on your juror summons.
4. Today's Date*
   Today's Date
6. SYMPTOMS NOW OR WITHIN 14 DAYS OF DATE OF REPORTED JUROR SERVICE.*

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

   1. Fever (above 99.6)
   2. Change in taste or smell
   3. Cough
   4. Nausea or Vomiting
   5. Headache
   6. Shortness of breath/Difficulty Breathing
   7. Diarrhea
   8. Chills
   9. Muscle pain or body aches
   10. Sore throat
   11. Fatigue
   12. Congestion or Runny nose
   13. None of the above apply to myself or a member of my household
8. Certification

   1. I certify that NONE of the symptoms have been experienced by me or a member of my household now or within 14 days of my scheduled date of service.
9. Today's Date*
   Today's Date
11. If you are experiencing any of the above symptoms, contact the court at (361) 485-3050 before reporting on the date of your scheduled service.
13. CONTACT HISTORY*

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

    1. I or a member of my household has been diagnosed with COVID-19 within the past 30 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 self-quarantining because of a possible COVID-19 exposure
    4. None of the above apply
15. 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.
17. Check this box only if the above COVID-19 related excuse or postponement applies to you.

    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.
19. Prospective jurors are encouraged to wear a face covering while they are in the courthouse.

    We understand that during and after the COVID-19 pandemic citizens may  have  reservations  about  attending   Jury Duty.  We would like to let you know what the City of Victoria Municipal Court is doing to ensure your safety.

    Staff will be cleaning between each proceeding and docket sizes will be limited in order to ensure jurors remain safe and healthy. Social distancing will be encouraged during the proceedings. Jurors  will have  assigned seating and will have  at least  six  feet of social distancing for the duration of their service. Masks are strongly encouraged for the protection of vulnerable persons. We will continue to work with our partners to ensure the safest possible environment as citizens perform their civic duty.

21. Certification*

    1. I certify that the above is true and correct.
23. First and Last Name*
24. Today's Date*
    Today's Date
26. Driver's License or Photo Identification*
27. Any other necessary documentation (Optional)
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

* indicates a required field