United States District Court - District of Massachusetts
Health Screening Questionnaire
First Name:
Last Name:
E-Mail:
Office:
Select one
Boston
Springfield
Worcester
Juror Type:
Select one
Petit Juror
Grand Juror
Judge:
Select one
First Day Juror - Monday
First Day Juror - Tuesday
First Day Juror - Wednesday
First Day Juror - Thursday
Judge Boal
Judge Bowler
Judge Burroughs
Judge Cabell
Judge Casper
Judge Collings
Judge Dein
Judge Gorton
Judge Harrington
Judge Hennessy
Judge Hillman
Judge Kelley
Judge Mastroianni
Judge Neiman
Judge Niedermeier
Judge O'Toole
Judge Ponsor
Judge Robertson
Judge Saris
Judge Saylor
Judge Sorokin
Judge Stearns
Judge Talwani
Judge Wolf
Judge Woodlock
Judge Young
Judge Zobel
Grand Jury Day:
Select one
Monday
Tuesday
Wednesday
Thursday
Friday
In the past ten days
, have you experienced any of the following symptoms:
Yes
No
Cough
Yes
No
Shortness of breath or difficulty breathing
Yes
No
Fever (temperature at or above 100.4), felt feverish or experienced shaking chills
Yes
No
Diarrhea or vomiting
Yes
No
Muscle pain
Yes
No
Sore throat
Yes
No
New loss of taste or smell
In the past fourteen days
, have you been awaiting COVID-19 test results?
Yes
No
Did you take the COVID-19 test as the result of experiencing symptoms of COVID-19 or because you had "close contact" with a person who tested positive for COVID-19? (The definition of "close contact" is "someone with whom you have been within 6 feet of for at least 10-15 minutes while symptomatic or within 48 hours before symptom onset").
Yes
No
In the past fourteen days
, have you, to your knowledge, been in "close contact" with someone with COVID-19? (The definition of "close contact" is "someone with whom you have been within 6 feet of for at least 10-15 minutes while symptomatic or within 48 hours before symptom onset").
Yes
No
In the past fourteen days
, have you been ordered by a public health authority or medical professional to isolate or quarantine due to COVID-19?
Yes
No
Submit
