New Hampshire Employee COVID-19 Office Entry Health Check Question Title * 1. Date Date / Time Date Time AM/PM - AM PM Question Title * 2. Employee Name Question Title * 3. Have you been in close contact with a confirmed case of COVID-19? Yes No Question Title * 4. Have you had a fever or felt feverish in the last 72 hours? Yes No Question Title * 5. Are you experiencing any respiratory symptoms including a runny nose, sore throat, cough, or shortness of breath? Yes No Question Title * 6. Are you experiencing any new muscle aches or chills? Yes No Question Title * 7. Have you experienced any new change in your sense of taste or smell? Yes No Question Title * 8. What is your temperature today? Question Title * 9. My answers are truthful and answered to the best of my ability. Yes No Done