Skip to content

New Hampshire Employee COVID-19 Office Entry Health Check

1.Date
Date / Time
Time
:
2.Employee Name
3.Have you been in close contact with a confirmed case of COVID-19?
4.Have you had a fever or felt feverish in the last 72 hours?
5.Are you experiencing any respiratory symptoms including a runny nose, sore throat, cough, or shortness of breath?
6.Are you experiencing any new muscle aches or chills?
7.Have you experienced any new change in your sense of taste or smell?
8.What is your temperature today?
9.My answers are truthful and answered to the best of my ability.