MEDICAL EXCUSE REQUEST
REQUEST FOR EXCUSE FROM JURY DUTY - MEDICAL
FOR JUROR/PROSPECTIVE JUROR:__________________________________________________
(Required)
9-DIGIT BAR CODE PARTICIPANT NUMBER:_________________________________________
(Required)
This request is for a permanent excuse from a QUALIFICATION QUESTIONNAIRE:______________
This request is in response to a SUMMONS, date when your service begins: ____________________
Check the category closest to what your request is based on: [ ] Health or Medical (see section titled Medical Excuse Request below) [ ] Other (Explain in the medical statement section or in a separate letter)
MEDICAL EXCUSE REQUEST
Your medical provider should explain your medical condition using this form or in a letter. The statement must include WHY you need to be excused, the DAYS/DATES you need to be excused and WHEN YOU MAY BE ABLE TO SERVE in the future.
Please do not ask court staff to contact your medical provider. It is the juror=s responsibility to provide the required documentation. Any request that cannot be easily read will automatically be denied.
Attention Medical Provider. Using the medical statement section of this form or in a separate letter, please briefly state the health or medical condition(s) the patient listed at the top of this form has that you feel will prevent he or she from serving as a federal juror. You do not have to provide personal information on the specific medical condition. If the individual is gainfully employed outside their residence, please indicate why serving on a jury would be more difficult than the requirements of their employment. If the medical condition is temporary, please indicate such, as well as when he or she will be able to serve in the future. If the medical or health condition is chronic and the individual should be permanently excused, please indicate this. The information you provide must be based on your knowledge of this individual=s health and medical condition. Do not indicate that the patient merely feels he or she should be excused as this is incomplete information which will automatically invalidate the request and the request will be considered denied. Please print and sign your name and the name of the medical office you are affiliated with. Thank you.
Please do not ask court staff to contact your medical provider. It is the juror=s responsibility to obtain the required information.
Excuse requests cannot be accepted on the date you are scheduled to appear for jury duty. You should mail this form as soon as possible to: U.S. District Court, 324 W. Market St., Greensboro, NC 27401 Attn: Jury.
YOU MUST ALSO RETURN YOUR COMPLETED QUALIFICATION QUESTIONNAIRE OR THE COMPLETED BOTTOM PORTION OF YOUR JURY SUMMONS
MEDICAL STATEMENT OF NEED FOR EXCUSE FROM JURY DUTY
FOR JUROR/PROSPECTIVE JUROR: _____________________________________________________
(Required)
9-DIGIT BAR CODE PARTICIPANT NUMBER: ____________________________________________
(Required)
_______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________
__________________________________ ___________________________________________
Signature of Medical Provider
Printed Name of Medical Office
Date
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- physician powerchart training manual version 3
- doctor s first report of occupational injury or
- family and medical leave of absence request
- all of the following notes and more are included in our
- forms and sample letters ionos
- free printable medical forms doctor referral form
- medical excuse form and instructions
- medical excuse request
- sample jury excuse letter 5th district dental society
- doctor s note to return to school
Related searches
- free printable doctors excuse notes
- free printable medical excuse forms
- free fillable doctor excuse form
- printable request for medical records
- pdf doctors excuse for work
- medical records request form pdf
- blank printable doctor excuse form
- free editable doctor excuse template
- doctor excuse for work free print out
- doctor excuse form for work
- printable doctor excuse for work
- hardship excuse for jury duty