Safer at Home Universal Guidelines
COVID-19 Screening Form
In compliance with the Safer at Home universal guidelines enacted by the State of New Hampshire on June 15, 2020, CCSNH
employees, students or visitors to campus who have been scheduled to be onsite, must be screened daily prior to entering
the campus. This screening must be completed by employees, students or visitors only on days when they are scheduled to
be onsite. Please complete the following screening information and return the completed form which will be submitted
directly to the safety staff and the institution’s human resources 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.
Name:_____________________________________ Are you (check one): Employee
Student
Visitor
CCSNH Institution: Great Bay Community College _________ Time:___________________ AM/PM
Title, Program or Company name:________________________________________
Section 2.
1. I attest that I have taken and recorded my temperature prior to arriving at campus and that my temperature
was:
[ ] 100.4 degrees Fahrenheit or lower. [ ] Higher than 100.4 degrees Fahrenheit
2. Have you been in close contact with a confirmed case of COVID-19 within the last 14 days? [ ] Yes [ ] No
(Close contact is defined as: a) being within 6 feet of a known or suspected COVID-19 case for greater than 15 minutes; 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 24 hours? [ ] Yes [ ] No
4. Are you experiencing any new respiratory symptoms including a runny nose, sore throat, cough,
or shortness of breath? [ ] Yes [ ] No
5. Are you experiencing any new muscle aches, chills or severe fatigue? [ ] Yes [ ] No
6. Have you experienced any new changes in your sense of taste or smell? [ ] Yes [ ] No
7. Are you experiencing any new gastrointestinal symptoms (nausea, vomiting, or diarrhea)? [ ] Yes [ ] No
8. Have you traveled in the past 14 days internationally (outside of the U.S.), by cruise ship, or outside of New
England (NH, VT, RI, CT, MA, and ME)? [ ] Yes [ ] No
If you answered yes to any of the questions above or have a temperature that exceeds 100.4 degrees Fahrenheit, you will
need to remain at home or leave the workplace and report home, and contact your Human Resources Office.
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.
______________________________________________________ ________________________
Signature`` Date
DLA: 8-19-2020
