Safer at Home Universal Guidelines
COVID-19 Visitor Screening
In compliance with the Safer at Home universal guidelines enacted by the State of New Hampshire on June 15, 2020, CCSNH
visitors who have been scheduled to enter a CCSNH facility must be screened daily prior to entering the facility. This
screening must be completed only on days when visitors are scheduled to come onsite. Please complete the following
screening information and return the completed form to the CCSNH employee with whom you have arranged your visit.
The information collected will be used only for the purpose of maintaining safe and healthy business operations and shall
be maintained as confidential.
Sec
tion 1.
Date:
Visitor Name:
CCSNH Institution: Nashua Community College
Reason for Visit:
Section 2.
1. I attest that I have taken and recorded my temperature prior to arriving at work and that my
temperature was:
[ ] 100.0 degrees Fahrenheit or lower. [ ] Higher than 100.0 degrees Fahrenheit
2. Have you been in close contact with a confirmed case of COVID-19? [ ] Yes [ ] No
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? [ ] Yes [ ] No
4. Are you experiencing any respiratory symptoms including a running nose, sore throat, cough, or
shortness of breath? [ ] Yes [ ] No
5. Are you experiencing any new muscle aches or chills? [ ] Yes [ ] No
6. Have you experienced any new change in your sense of taste or smell? [ ] Yes [ ] No
If you answered yes to any of the questions above or have a temperature that exceeds 100.0 degrees Fahrenheit, you will
not be permitted to enter a CCSNH facility until you are free of fever, and any other symptoms for at least 72 hours,
wi
thout 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 exclusion from CCSNH facilities.
Signature of CCSNH Visitor Date
