City of Victoria Form Center

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Jury Service COVID-19 Pre-Screening Questionnaire

  1. 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.
  2. SYMPTOMS NOW OR WITHIN 14 DAYS OF DATE OF REPORTED JUROR SERVICE.*
    Check all that apply to you or a member of your household
  3. Certification*
  4. 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.
  5. CONTACT HISTORY*
    Check any of the below that apply to you or a member of your household.
  6. 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.
  7. Check this box only if the above COVID-19 related excuse or postponement applies to you.
  8. Prospective jurors are required to wear a face covering while they are in the courthouse.
    Individuals are encouraged to bring a cloth face covering with them. If an individual does not have a cloth face covering, a disposable face mask will be provided.
  9. Certification*
  10. Leave This Blank:

  11. This field is not part of the form submission.