Physician’s Statement for Medical Excuse
Participant Number: ___________________________________________
Patient Name: ________________________________________________
Patient Address: ______________________________________________
To Federal Court Jury Clerk:
General Excuse from Jury Service
Please excuse the above named patient from federal jury duty due to:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
It is medically advisable that the patient refrain from this type of service.
If this patient is employed please explain why it would be more detrimental to them to
serve on the jury rather than their normal employment.
________________________________________________________________________
________________________________________________________________________
Temporary Excuse from Jury Service
Due to:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Please provide date when available to serve as a juror: ____________________________
Name of Physician:___________________________________
Office Address:______________________________________
Telephone Number:___________________________________
Signature of Physician:______________________________ Date:________________
Note: This form must be submitted by the prospective juror within five business
days.
