Juror Self-Certification of Vaccination Status
Superior Court, Contra Costa County
Juror Name: _________________________________________
As part of the Court’s commitment to ensure the safety of its employees and court users, and in
compliance with all applicable and recommended health and safety orders, we are requiring that our
employees (as well as contractors, volunteers, and jurors) provide information about their COVID-19
vaccination status if an individual requests to enter and remain in a court facility without wearing a
face mask.
Please note that you are required to provide accurate information about your vaccination status in
response to the questions below, or alternatively may decline to provide your vaccination status. If
you decline to provide information about your vaccination status, we will assume you are
unvaccinated for purposes of any rules or requirements at court facilities that are different for
vaccinated or unvaccinated court users and employees.
For purposes of this certification, you are considered “fully vaccinated” two weeks after completing
the second dose of a two-dose COVID-19 vaccine (e.g., Pfizer or Moderna) or two weeks after
receiving a single dose of a one-dose vaccine (e.g., Johnson & Johnson/Janssen).
Please check the statement below if it accurately describes your vaccination status:
____ I am fully vaccinated.
I understand that I am required to provide accurate information in response to the question above
and I affirm that I have accurately and truthfully answered the question above. I also understand that
if I stated that I am fully vaccinated, the court may require documentation of my vaccination status
(e.g., a copy of my vaccine card or other similar official medical document confirming vaccination
status).
Signature: _________________________________________
Date: _________________________________________
Local Court Form – Mandatory
J-017 Rev. 6/18/21
