Date (mm/dd/yyyy):
First Name:
Last Name:
Department:	Admin Accounting Facilities IFA IT Operations Lending Loan Ops Retail Risk Mgt
Location:	ASC Bedford Boscawen Bristol Gilford Goffstown Main Office Main Office IFA Merrimack Rochester Tilton Upper Central
Have you been in close contact with a confirmed case of COVID-19?:	No Yes
Have you had a fever or felt feverish in the last 72 hours?:	No Yes
Are you experiencing any respiratory symptoms including a runny nose; sore throat; cough or shortness of breath?:	No Yes
Are you experiencing gastrointestinal symptoms such as nausea; vomiting or diarrhea?:	No Yes
Are you experiencing any new muscle aches or chills?:	No Yes
Have you experienced any new changes in taste or smell?:	No Yes
Are you running a fever over 100 degrees?:	No Yes