Medical Excuse From Jury Duty - Based on a Serious Health Condition

Sep 16, 2026

Uploaded by Kurz

Medical Excuse From Jury Duty is a court form used when a potential juror’s serious physical or mental health condition prevents timely appearance or service. The juror first provides identifying information and, if relevant, is directed to discuss requested accommodations with the jury manager. The treating health care provider certifies the patient, confirms the patient is a current patient, and specifies the excusal duration and functional limitations. The provider signs with license details and is instructed not to include medical records.

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CategoryForms

FormatPDF

Pages1

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Medical excuse from jury duty

Juror information and accommodation note

Health care provider certification section

Exclusion duration and functional limitations

Physician signature and contact instructions

MEDICAL EXCUSE FROM JURY DUTY BASED ON A SERIOUS HEALTH CONDITION Name: Date of Birth: Jury Service Start Date: NOTE: The Court is happy to provide accommodations to potential jurors who may need an accommodation for a health condition. Before seeking an excuse from jury service, if you or your provider feel that an accommodation may facilitate your ability to serve on a jury, STOP HERE and please discuss your requested accommodation with the jury manager. PATIENTS SHOULD COMPLETE THE ABOVE SECTION, AND THEN ASK THEIR TREATING HEALTH CARE PROVIDER TO COMPLETE THE SECTION BELOW. | Dear Health Care Provider:
The patient identified above is scheduled for jury duty on the date indicated. Iowa law makes jury service a fundamental obligation of all citizens and the bedrock of our court system. Individuals who believe that they cannot serve on jury duty due to their health must have their treating health care provider certify that a serious physical or mental health condition prevents them from fulfilling their legal obligation to appear for jury duty.
Please see the note above about accommodations. If you feel that there is no accommodation that may allow participation, please complete the certification below.
WEARE NOT REQUESTING ANY SPECIFIC DETAILS ABOUT AN INDIVIDUAL’S HEALTH OR MEDICAL CONDITION(S). PLEASE DO NOT PROVIDE MEDICAL RECORDS OR MEDICAL INFORMATION.
CERTIFICATION
I hereby swear and affirm that the individual identified above is my patient, and that he/she has a serious physical or mental health condition that prevents him/her from being able to appear for and serve on jury duty at this time.
The nature of this condition requires my patient to be excused from jury service for the following period of time:
Short-term: Please estimate when jury service is possible within the next twelve months: .
Mid-term: Excuse for this cycle. Patient will be able to serve upon becoming eligible again in two years.
Long-term: Forever. If you have indicated long-term please answer the following questions:
1. What aspect(s) of jury duty is not possible due to the patient’s condition(s)?
Appear in person at the courthouse
Cognitively receive and evaluate information that is presented during the proceeding
Sit quietly during the proceeding, for periods of approximately two hours without a break, which may continue the entire day (some trials may last more than one day) . Please note that jurors maybe permitted to stand up and stretch more frequently.
Other:
2. If you have approved this patient to go to work, why would it be more detrimental for him/her to serve
on a jury than to go to work?
NOTE: A person who knowingly makes a false affidavit, statement, or claim, for the purpose of relieving the person or another person from juror service, commits contempt. Iowa Code § 607A.7. | | | | | --- | --- | --- | --- | | Physician Signature | Printed Name | Date | Physician’s License No. | Practice Name Practice Phone No. If you have any questions about this form, please call the Jury Manager at your County Clerk’s Office. Feel free to attach additional pages if you need more space.

FAQs

What must the patient do before asking for a jury duty excuse?

The patient completes the section above and, if an accommodation may facilitate serving, discusses the requested accommodation with the jury manager before seeking an excuse from jury service.

What does the health care provider need to certify?

The provider certifies that the patient has a serious physical or mental health condition that prevents appearing for and serving on jury duty at this time, without providing specific medical details or records.

How are short-term, mid-term, and long-term excuses determined on the form?

The provider estimates when jury service may be possible within twelve months for short-term, states excusal for the current cycle with eligibility in two years for mid-term, or marks it as long-term ("Forever") and answers additional questions about what aspects of jury duty are impossible.

Sep 16, 2026

Uploaded by Kurz