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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.

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* Your Name:

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* Does your temperature exceed 100.4 degrees Fahrenheit today?

Yes

No

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