Form Num. 13-21891-360 Revision January 1, 2019
Superior Court
of
California,
County
of
San Bernardino
Confidential Declaration of Medical Excusal
This form is to be completed and signed by a physician on behalf of their patient, who is unable to appear for jury service.
The jury commissioner has the discretion to accept an excuse without a personal appearance. All excuses must be in
writing and indicate the basis for the request.
As defined in Code of Civil Procedure, section 209, and the California Rules of Court, Rule 2.1008(d) (5), a prospective juror
who has a physical or mental disability or impairment, not affecting that person’s competence to act as a juror that would
expose the potential juror to undue risk of mental or physical harm, may be excused. In any individual case, unless the
person is aged 70 years or older, the prospective juror is required to furnish verification or a method of verification of the
disability or impairment, its probable duration, and the particular reasons for the person’s inability to serve as a juror.
As defined in California Rules of Court, Rule 2.1009, a prospective juror with a disability whose condition is unlikely to
resolve and who is unable for the foreseeable future to serve as a juror to seek a permanent medical excuse from jury
service, may be permanently excused. In any individual case, the prospective juror is required to furnish in writing,
supporting documentation from the treating health care provider.
Jurors are summoned in accordance with the standards prescribed by the Judicial Council. While we cannot guarantee that
no future summons will be sent, the Court will honor a copy of the permanent medical excusal.
Complete Information Below
To be completed by Summoned Juror
Prospective Juror’s Name:
Permanent Medical Excusal: The prospective Juror requests a permanent excusal from jury service based upon the
fact that they are seventy (70) years of age or older, and have a physical and/or mental disability or impairment that
would cause them undue risk of mental or physical harm. Date of Birth: (MM/DD/YYYY) (96)
To be completed by Physician
I certify under penalty of perjury that the foregoing is true and correct.
Temporary Medical Excusal: The prospective juror has requested a temporary excusal from jury service based a
physical and/or mental disability or impairment that would cause them undue risk of mental or physical harm. (32)
The juror should be excused until
Permanent Medical Excusal: The prospective juror has requested a permanent excusal based upon a physical and/or
mental disability or impairment that would render them incapable of performing jury service for the foreseeable
Physician’s Printed Name:
Email form to Jury@sb-court.org Fax form to (909) 521-3661
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