REQUEST FOR MEDICAL DISQUALIFICATION FROM JURY SERVICESTATE OF CONNECTICUTJURY ADMINISTRATIONJDJA47 Rev. 522 C.G.S. 51217(a)(9), (c)(1)www.jud.ct.govTo request a medical disqualification, please.
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How to fill out the REQUEST FOR MEDICAL DISQUALIFICATION FROM JURY SERVICE online
Completing the request for medical disqualification from jury service is a straightforward process that can help individuals who are unable to serve due to health reasons. This guide will walk you through each step required to successfully fill out the form online.
Follow the steps to complete your request effectively.
- Press the ‘Get Form’ button to access the form. This will allow you to open and edit the document as needed.
- In Part I, you will need to provide your personal information, including your name, address, juror identification number, and date of birth. Ensure all entered details are accurate to avoid processing delays.
- Indicate your disqualification reason by stating that you are unable to fulfill jury service due to a physical or mental disability. You might also want to include the opinion of your licensed health care provider.
- Part II must be completed by your licensed health care provider. Ensure that this section is filled out clearly, as legibility is crucial for your request to be processed.
- Your health care provider should specify whether the disqualification is temporary (one year) or permanent. The provider will also need to print their name, title, business address, and contact number.
- Once both parts of the form are completed, save your changes. You can then download, print, or share the form as needed.
- Submit the completed form by faxing it to (860) 263-2770, emailing it to Jury.Administration@jud.ct.gov, or mailing it to Jury Administration, P.O. Box 260448, Hartford, CT 06126-0448.
Complete your REQUEST FOR MEDICAL DISQUALIFICATION FORM online today to ensure your needs are met.
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