REQUEST FOR MEDICAL DISQUALIFICATION FROM JURY SERVICE - ct
REQUEST FOR MEDICAL DISQUALIFICATION FROM JURY SERVICE
JD-JA-47 Rev. 5-22
C.G.S. ? 51-217(a)(9), (c)(1)
STATE OF CONNECTICUT JURY ADMINISTRATION
jud.
To request a medical disqualification, please fill out Part I of this form and have a licensed health care provider complete Part II of this form. Do not take this request to court. Please fax, or scan and e-mail this form to Jury Administration. The fax number is (860) 263-2770. The e-mail address is Jury.Administration@jud.. You may also mail this form directly to Jury Administration, P.O. Box 260448, Hartford, CT 06126-0448. Jurors whose medical disqualification is approved by Jury Administration are not required to come to court. You will be notified of Jury Administration's decision by mail.
Part I (to be completed by Juror)
Name of Juror Address of Juror Juror identification number (letters and numbers)
Date of birth
I claim that I am disqualified from jury service due to physical or mental disability in accordance with the following opinion of my licensed health care provider.
Part II (to be completed by Licensed Health Care Provider)
Please note that all responses must be legible in order for Jury Administration to determine your patient's eligibility for disqualification.
In my opinion, this patient is not capable, by reason of physical or mental disability, of rendering satisfactory juror service because such person is not able to perform a sedentary job requiring close attention for six (6) hours per day with short work breaks in the morning and afternoon sessions, for at least three (3) consecutive business days. (Select one of the following)
This patient should be disqualified from jury service for one year only.
OR
This patient should be permanently* disqualified from jury service.
*For a permanent medical disqualification, state law requires that a licensed physician (Medical Doctor (M.D.) or Doctor of Osteopathy (D.O.)) or Physician Assistant (P.A.) or Advanced Practice Registered Nurse (A.P.R.N.) complete this part of the form.
Name of licensed health care provider
Title
Business address
Business telephone number
Signed (Licensed health care provider)
Date
ADA NOTICE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at jud.ADA.
Print Form
Reset Form
................
................
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
- request for excuse from jury service
- sample jury excuse letter 5th district dental society
- statement for jurors to be excused phelps county
- request for medical disqualification from jury service ct
- jury service request to be disqualified postponed or excused california
- medical excuse from jury duty based on serious health condition
- confidential declaration of medical excusal
- request for excusal from jury duty
- grounds for requesting temporary or permanent excuse united states courts
- request for excuse from jury service maricopa county arizona
Related searches
- request for hearing student
- request for hearing student loan
- request for hearing department of educat
- request for hearing student loan garnishment
- request for hearing department of education
- medical work from home positions
- printable request for medical records
- online medical jobs from home
- request for medical records letter example
- request my tax transcript from irs
- free printable request for medical records
- medical excuse from jury duty