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150 S 4th E St
Mountain Home, ID 83647
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ELECTED OFFICIALS
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Making Tax Payments for Elmore County, ID
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DEPARTMENTS
Department of Motor Vehicles
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Elmore County District Court
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Covid-19 Daily Questionnaire
Covid-19 Daily Questionnaire
Elmore County Courthouse Juror Covid-19 Questionnaire
Name
(Required)
First
Last
Juror Number
(Required)
Are you currently experiencing any of the following syptoms?
(Required)
Yes
No
What symptoms, if any, are you currently experiencing? (Check all that apply)
Chills
Cough
Shorness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Conjunctivitis (pink eye)
Nausea or vomiting
Diarrhea
Do you feel feverish or have a temperature above 100° F?
(Required)
Yes
No
Since you were last here, has anyone in your household tested positive for SARS-CoV-2 or COVID-19 or experienced any of the symptoms listed above?
(Required)
Yes
No
Since you were last here, have you been in close contact with anyone other than a household member who has tested positive for SARSCoV-2 or COVID-19?
(Required)
Yes
No
Since you were last here, have you tested positive for SARS-CoV-2 or COVID-19 or been told by your health care provider that you might have COVID-19?
(Required)
Yes
No
Since you were last here, have you been notified by your public health district that you were in close contact with someone who tested positive for SARS-CoV-2 or COVID-19?
(Required)
Yes
No
Since you were last here, have you been tested for SARS-CoV-2 or COVID-19 and are waiting to receive test results?
(Required)
Yes
No
Pursuant to I.C.§ 9-140, I certify or declare under penalty of perjury pursuant to the law of the State of Idaho that the responses are true and correct to the best of my knowledge. I acknowledge that a willful misrepresentation is punishable as a misdemeanor pursuant to I.C. § 2-208(6).
(Required)
First
Last
Date
(Required)
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.
