Please Note: This information is solely for HR use and will be deleted once its purpose is completed. HR is assessing this information in order to ensure the safety of our employees and operations. If you do not receive a phone call from HR and are looking to be approved to Return to Work, please contact either HRMedical@dos.nh.gov or call 223-8000 option 3 Please select who is filling out this form*EmployeeOtherNamePhoneEmailPlease supply your email so that you can receive a copy of what you have submitted today for your records as well as the instructions on what to do next. We asked for a personal email as you are not at work to receive work email.)= The date in which the employee is calling out.* Date Format: MM slash DD slash YYYY Demographic and contact informationEmployee Name*Please provide the employees full name that is calling out.Personal Phone Number*Please provide the best contact telephone number for the employee.Personal Email to contact Division*AdminCommissioner's officeDESCDMVFMOFSTEMSHearingsHighway SafetyHSEMState PoliceSupervisor's nameThis information is to notify your supervisor that you will not be at work. No additional information other than your name and that you called out will be sent to your supervisor.Your supervisor's email address Please provide your supervisor's email address.What was your reason for being out?Experiencing any of the following: runny nose, nasal congestion, sore throat, cough, shortness of breath, muscle aches, headache, fatigue, nausea, vomiting, diarrhea, or changes in your sense of taste or smellTested Positive for COVID19Close contact to positive/suspected COVID person (non-household)Household member is experiencing COVID like symptoms or has tested positiveI have travel out of New England in the past 10 daysApproved FMLA EventNon-work Related InjuryWork Related InjuryOtherCOVID like symptoms or a positive COVID testPlease identify the any of the symptoms you are experiencing?* Fever Chills Fatigue Shortness of Breath Sore Throat Loss of Taste Loss of Smell New Onset of Cough Atypical Muscle Pain (body aches) Atypical Headache Congestion/Runny nose Nausea Vomiting Diarrhea I do not currently have any symptoms Date in which symptoms started* Date Format: MM slash DD slash YYYY Have you been tested for COVID?*YesNoI do not plan on getting testedWhat date did you get tested?* Date Format: MM slash DD slash YYYY For us to clear you to return, we need to assess the risk for COVID. Getting a test will assist us in keeping our coworkers and their friends and families safe. Please find the list of places you may obtain a COVID test by clicking here. Once you receive your test results please resubmit this form. Without a negative test you will have to remain out of work for a minimum of 10 days from the onset of symptoms and be cleared to return by Human Resources.Have you received your test results*YesNoPlease remain out of work and isolate until you receive your test results. Once you receive your test result please resubmit this form.What were your COVID test results?*Any inconclusive result will not be accepted, you will need to have a PCR test.PositiveNegativeWith a positive test you should self-isolate yourself and follow the DHHS self-isolation guidance.Are your symptoms improving?*YesNoHave you taken fever reducing medications in the last 24 hours?*YesNoYes – You are clear to return to work. Please resubmit this form when your symptoms are improving and you are no longer taking fever reducing medications.Close contact to positive/suspected COVID person (non-household)Did the person you had close contact with test positive for COVID-19?*YesNo, they are pending results.They do not plan on getting tested.What was the date of your exposure? Date Format: MM slash DD slash YYYY If not known, please leave blank.You are not cleared to return to work at this time. You should quarantine based on the DHHS Self-Quarantine guidance for 14 days from the date of the exposure. Please contact hrmedical@dos.nh.gov when you know the results of the test for further instructions.Please remain out of work and quarantine yourself. For more information on close contact and quarantine, visit the CDC website. Please contact HRmedical@dos.nh.gov today to discuss what your return to work date may be. Household member is experiencing COVID like symptoms or has tested positivePlease identify the any of the symptoms they are experiencing?* Fever Chills Fatigue Shortness of Breath Sore Throat Loss of Taste Loss of Smell New Onset of Cough Atypical Muscle Pain (body aches) Atypical Headache Congestion/Runny nose Nausea Vomiting Diarrhea They do not currently have any symptoms Has your household member been tested for COVID?*YesNoThey do not plan on getting testedFor us to clear you to return, we need to assess the risk for COVID. Getting a test will assist us in keeping our coworkers and their friends and families safe. Please find the list of places you may obtain a COVID test here.. Once you receive your test results please resubmit this form.At this time you are not cleared to return to work. Someone from Human Resources will be contacting you.Did they receive their COVID test results?*Yes - Positive resultYes - Negative resultNo - still waiting for their resultsAt this time you are not cleared to return to work. With a positive test you should have your household member self-isolate themselves by following the DHHS self-isolation guidance.You are clear to return to work. You are not clear to return. Please resubmit this form when your results are in.I have traveled out of New England in the past 10 daysWhat was the date in which you returned to New England?* Date Format: MM slash DD slash YYYY How you received a negative PCR COVID test on or after your 7th day in New England?*YesNoUpload a copy of your negative PCR COVID TestHave you been fully vaccinated and more than 14 days have passed since you received your second vaccine dose?*YesNoHave you tested positive for COVID19 in the last 90 days?YesNoYou can also email your test results to hrmedical@dos.nh.gov or fax your results to 603-271-5890.You are not clear to return. Please try again when you have met the quarantine requirement. Approved FMLA PlanDo you have an approved FMLA plan?*YesNoBy choosing yes you are certifying that HR has approved you for a current FMLA plan and that today’s call out is consistent with that FMLA plan.Please contact hrmedical@dos.nh.gov immediately.Non-work Related InjuryYou have been cleared to return from work once you are able to.Work Related InjuryA message has been sent to Human Resources and someone will be contacting you.OtherWhat is the reason you are out?Additional InformationPlease provide any additional information