Safer at Home Universal Guidelines
COVID-19 Employee Screening
Date:
In compliance with the Safer at Home universal guidelines enacted by the State of New Hampshire on June 15, 2020, CCSNH
employees who have been scheduled to work onsite must be screened daily prior to reporting to work. This screening must be
completed by employees only on days when they are scheduled to work onsite.
Please complete the following screening information and return the completed form by selecting the "submit" button on the
bottom of the form for forwarding to your institution’s Human Resources/Campus Safety Office. The information collected
will be used only for the purpose of maintaining safe and healthy business operations and shall be maintained as confidential.
Section 1.
Employee Name:
CCSNH Institution:
Position Title:
Section 2.
1. I attest that I have taken and recorded my temperature prior to arriving at work and that my
temperature was:
2. Have you been in close contact with a confirmed case of COVID-19?
(Close contact is defined as: a) being within 6 feet of a known or suspected COVID-19 case for a prolonged period of time;
close contact can occur while caring for, living with, visiting, or sharing a healthcare waiting area or room with a known or
suspected COVID-19 case; or b) having direct contact with infectious secretions of a COVID-19 case (e.g., being coughed on))
NOTE: Healthcare workers caring for COVID-19 patients while wearing appropriate personal protective equipment should
answer “no” to this question.
3. Have you had a fever or felt feverish in the last 72 hours?
4. Are you experiencing any respiratory symptoms including a runny nose, sore throat, cough, or
shortness of breath?
5. Are you experiencing any new muscle aches or chills?
6. Have you experienced any new change in your sense of taste or smell?
Yes NoYes No
If you answered yes to any of the questions above or have a temperature that exceeds 100.0 degrees Fahrenheit, you will
need to leave workplace and report home. You will not be permitted to return to on-site work until you are free of fever, and
any other symptoms for at least 72 hours, without using fever reducing or symptom altering medication.
Section 3. I attest that I have answered the above information truthfully. I understand that any falsification of information may
be grounds for corrective action, which may include disciplinary action.
Date:
Signature of Employee
DLA: 7-10-2020 CEB
Nashua Community College
[ ] 100.0 degrees Fahrenheit or lower.
[ ] Higher than 100.0 degrees Fahrenheit
