8th Judicial District of Kansas

ADDITIONAL JUROR QUESTIONNAIRE REGARDING COVID-19

The following questions will assist the court to determine your eligibility as a prospective juror. Kansas Supreme Court Rule 167 provides that juror questionnaires are not public records and are not subject to disclosure under the Kansas Open Records Act. Please contact the jury coordinator immediately if any answers to the following questions change.

Have you been exposed to COVID-19?*

Yes
No

If yes, approximate date of exposure:

Have you tested positive for COVID-19?*

Yes
No

If yes, approximate date of exposure:

Are you currently experiencing any symptoms of COVID-19 (including fever, cough, sore throat, respiratory illness, or difficulty breathing) and been told to quarantine?*

Yes
No

If yes, what date were you instructed to quarantine?

Are you an employee who has been laid off due to COVID-19 and have recently returned to work?*

Yes
No

If yes, where are you employed, how long were you laid off, and when did you return to work?

Are you over age 60, or a person of any age with an underlying medical condition that puts you at a higher risk of developing serious health complications from COVID-19?*

Yes
No

If yes, please explain:

Do you live with or provide direct care for a vulnerable person?*

Yes
No

If yes, please explain:

Do you have children at home who require your direct supervision due to school and/or daycare closings?*

NOTE: Only answer YES if there is NO ONE else in the household who can provide care during your jury service.

Yes
No

If yes, please explain:

Have you done any of the following in the last 14-days:

If you answer “yes” to any of the below questions, your jury service may be deferred. You will receive written confirmation of the court’s determination by electronic or postal mail.

For your safety and the safety of others, please place a checkmark on the applicable line:*

I have not had a COVID vaccination
I have had one COVID vaccination but still need a second
I am fully vaccinated for COVID-19

I SWEAR OR AFFIRM UNDER THE PENALTIES OF PERJURY THAT THE ABOVE STATEMENTS, REPRESENTATIONS, AND ANSWERS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.

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Geary Juror Questionnaire - 2021-01-01 to 2021-04-30

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