REQUEST FOR MEDICAL EXCUSE FROM JURY SERVICE A.R.S. § 21-202 If a patient requests to be excused from jury service for reasons related to mental or physical conditions, Arizona law requires a written statement from a physician, physician assistant, or registered nurse practitioner ("RNP") licensed by the state of Arizona. If a prospective juror does not have a physician, physician assistant, or RNP, a professional caregiver may complete this form. The professional caregiver must be deemed acceptable by the court or jury commissioner for this purpose. Some mental and physical problems do not warrant an excuse from service but may warrant a postponement. For any excuse that you provide, please be aware that you may be called to testify before the court about your representations regarding your patient's inability to perform jury service. ALL questions must be answered legibly. If not, this application will be considered incomplete and invalid. Patient Name: Address: DOB: Juror Badge No.: State: Zip Code: Describe any mobility, physical or mental restrictions that make the prospective juror unfit for jury service: List the specific symptoms that make this person unfit for jury service and state how long these symptoms have occurred: When will this person be able to serve as a juror?: Is the patient: [ ] employed, [ ] unemployed, [ ] retired? Print Name of Physician, Physician Assistant, RNP, or Professional Caregiver: Business Address: Business Phone: Physician License Number: Specialty: State: Zip Code: Physician Assistant License Number: Nurse Practitioner Certificate Number: I swear or affirm under penalty of perjury under the laws of the State of Arizona that the contents of this document are true and correct to the best of my knowledge and belief. Date: Signature of Physician, Physician Assistant, RNP, or Professional Caregiver This document is not a public record and shall not be disclosed to the general public. A.R.S. § 21-202(B)(1)(c) Rev. May 2, 2014 American LegalNet, Inc. www.FormsWorkFlow.com