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Information
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