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2. Your health and well-being are of the utmost importance and we are committed to providing you with a safe environment in the courthouse. Anyone coming into the courthouse will be screened and part of our screening process includes this questionnaire. Please select either "yes" or "no". If you answer "yes" to any of these questions, you must immediately contact the Clerk of Court at 540-375-3067 or the Sheriff's Office at 540-375-3040 to report all affirmative answers.

4. Name*
6. 1. Within the last 14 days:
8. A) Have you had close contact, without the use of appropriate PPE, with someone who is currently sick with suspected or confirmed COVID-19?*

   1. Yes
   2. No
10. B) Have you traveled outside of the country/internationally?*

    1. Yes
    2. No
12. C) Have you experienced, or are you experiencing, any of the following (other than from a pre-existing non-COVID diagnosis):
14. a. Fever?*

    1. Yes
    2. No
15. b. Chills?*

    1. Yes
    2. No
16. c. Cough?*

    1. Yes
    2. No
18. d. Shortness of breath?*

    1. Yes
    2. No
19. e. Difficulty breathing?*

    1. Yes
    2. No
20. f. Fatigue?*

    1. Yes
    2. No
22. g. Muscle or body aches?*

    1. Yes
    2. No
23. h. Headaches?*

    1. Yes
    2. No
24. i. New loss of taste or smell?*

    1. Yes
    2. No
26. j. Sore throat?*

    1. Yes
    2. No
27. k. Congestion or runny nose?*

    1. Yes
    2. No
28. l. Nausea or vomiting?*

    1. Yes
    2. No
30. D) Have you been in close proximity to anyone who was experiencing any of the above listed symptoms?*

    1. Yes
    2. No
32. E) Have you had a temperature at or above 100 degrees?*

    1. Yes
    2. No
34. G) Have you, or a co-worker, or a member of your immediate family been directed to quarantine, isolate, or self-monitor?*

    1. Yes
    2. No
36. H) Have you been diagnosed with, or had contact with anyone who has been diagnosed with COVID-19, or resided with someone who has been diagnosed with, or had contact with someone who has been diagnosed with COVID-19?*

    1. Yes
    2. No
38. 2. Do you believe that your health or that of a relative or person with whom you reside may be endangered by you serving on a jury?*

    1. Yes
    2. No
40. 3. Have you been tested for COVID-19 and are awaiting results?*

    1. Yes
    2. No
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

* indicates a required field