Community Health Attestation

To promote the safety of the community and reduce the impact of COVID-19, New Hampshire is requiring employers to comply with the daily monitoring of employees temperatures and the documenting of responses to 5 questions.

Question Title

* Your Name:

Question Title

* Does your temperature exceed 100.4 degrees Fahrenheit today?

Question Title

* Please Answer the following 5 questions:

  Yes No
Have you been in close contact with a confirmed case of COVID-19 within the past 14 days?
Have you had a fever or felt feverish in the last 72 hours?
Are you experiencing any new respiratory symptoms including a runny nose, sore throat, cough, or shortness of breath?
Are you experiencing any new muscle aches or chills?
Are you experiencing any new change in your sense of taste or smell?