2. First Name*
3. Last Name*
4. Phone Number*
5. Jury Service begins on :*
   Jury Service begins on :
7. Summons Barcode Number*
9. 1. Are you 65 or older and been diagnosed with common COVID-19 comorbid conditions, such as: diabetes, obesity or high blood pressure?*

   1. YES

   1. NO
11. 2. Have you been diagnosed with or tested positive for COVID-19?*

    1. YES
    2. NO
13. 2b. If so, when?
15. 3. Have you been vaccinated against COVID-19?*

    1. YES (Fully Vaccinated)
    2. YES (Partially Vaccinated)
    3. NO
    4. PREFER NOT TO ANSWER
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17. 1. Receive an email copy of this form.
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