REQUEST FOR MEDICAL DISQUALIFICATION FROM JURY SERVICE JD-JA-47 New 11-16 C.G.S. § 51-217(a)(9), (c)(1) JURY ADMINISTRATION www.jud.ct.gov STATE OF CONNECTICUT To request a medical disqualification, please fill out Part I of this form and have a licensed health care provider complete Part II of this form. Do not take this notice to court. Please fax, or scan and e-mail this form to Jury Administration. The fax number is (860) 263-2770. The e-mail address is Jury.Administration@jud.ct.gov. You may also mail this form directly to Jury Administration, P.O. Box 260448, Hartford, CT 06126-0448. Jurors whose medical disqualification is approved are not required to come to court. Part I (to be completed by Juror) Name of Juror Address of Juror Juror identification number (letters and numbers) Date of birth I claim that I am disqualified from jury service due to physical or mental disability in accordance with the following opinion of my licensed health care provider. Part II (to be completed by Licensed Health Care Provider) Please note that all responses must be legible in order for Jury Administration to determine your patient's eligibility for disqualification. In my opinion, this patient is not capable, by reason of physical or mental disability, of rendering satisfactory juror service because such person is not able to perform a sedentary job requiring close attention for six (6) hours per day with short work breaks in the morning and afternoon sessions, for at least three (3) consecutive business days. ("X" only one of the following) This patient should be disqualified from jury service for one year only. OR This patient should be permanently* disqualified from jury service. *For a permanent medical disqualification, state law requires that a licensed physician (Medical Doctor (M.D.) or Doctor of Osteopathy (D.O.)) or Advanced Practice Registered Nurse (A.P.R.N.) complete this part of the form. Name of licensed health care provider Business address Signed (Licensed health care provider) Title Business telephone number Date ADA NOTICE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. American LegalNet, Inc. www.FormsWorkFlow.com