Published: 11/2019, CN: 12308
New Jersey Judiciary
Physician Certification in Support of
Medical Excuse Request
Practice Name and Address
Physician’s Office Telephone Number
Physician’s License Number
Patient (Juror) Full Name
Patient (Juror) Telephone Number
Patient (Juror) Email Address
I have examined the above named patient and attest that he/she is unable to serve when
summoned. At this time, this patient is unable to serve for:
*The Judiciary relies on disability determinations made by the Social Security Administration and Department of Veteran
Affairs to permanently excuse a juror from their service obligation. Please contact the Jury Management Office if you have
additional questions on medical excusals and disqualifications. The New Jersey Judiciary will, with advanced notice, provide
accommodations consistent with the Americans with Disabilities Act. ADA contacts for each county can be found at:
https://www.njcourts.gov/forms/12134_adatitleIIcontacts.pdf
NOTE: Please do not write, attach, or otherwise provide any private health information about the
patient. The Jury Management Office will never request this information.
If this patient is employed, please explain why it would be more detrimental for them to serve
their term of jury service than their normal employment.
I hereby certify and say that the foregoing statements made by me are true. I am aware that if
any of the foregoing statements made by me are willfully false, I am subject to punishment.
Name of Physician (Print Name)
