Stay at Home 2.0 Universal Guidelines
COVID-19 Employee Screening
In compliance with the Stay at Home 2.0 universal guidelines enacted by the State of New Hampshire on May 1, 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 to your supervisor or the designated
appointee at your institution for forwarding your 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.
Employee Name:_____________________________________ Date: _____________________
CCSNH Institution:____________________________________ Time:___________________ AM/PM
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:
[ ] 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 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 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).
3. Have you had a fever or felt feverish in the last 72 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 or chills? [ ] Yes [ ] No
6. Have you experienced any new changes 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
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.
_________________________________________________________ ________________________
Signature of CCSNH Employee Date
DLA: 5-21-2020