If a patient requests to be excused from jury service for reasons related to mental or physical conditions, Arizona law requires a written statement from a physician, physician assistant, or registered nurse practitioner (“RNP”) licensed by the state of Arizona. If a prospective juror does not have a physician, physician assistant, or RNP, a professional caregiver may complete this form. The professional caregiver must be deemed acceptable by the court or jury commissioner for this purpose.

Some mental and physical problems do not warrant an excuse from service but may warrant a postponement. For any excuse that you provide, please be aware that you may be called to testify before the court about your representations regarding your patient’s inability to perform jury service. ALL questions must be answered legibly. If not, this application will be considered incomplete and invalid.