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DOS Employee sick notification – DRAFT

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DOS Employee sick notification – DRAFT

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Please Note: This information is only shared with HR and will be deleted once its purpose is completed. No record will maintain of this information. HR is assessing this information for possible COVID-19 cases and maintaining employee’s safety only.

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*
- Employee
- Other
Name
Phone
Email
The date in which the employee is calling out.*
Date Format: MM slash DD slash YYYY
Demographic and contact information
Employee 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*
Supervisor's name
This information is to notify your supervisor that you will not be at work. No additional information other than you name and that you called out sick will be sent to your supervisor.
Your supervisor's email address

Please provide your supervisors email address.
What was your reason for being out?
- COVID like symptoms or a positive COVID test
- Close contact to positive/suspected COVID person (non-household)
- Household member is experiencing COVID like symptoms or has tested positive
- I have travel out of New England in the past 14 days
- Approved FMLA Event
- Non-work Related Injury
- Work Related Injury
- Other
COVID like symptoms or a positive COVID test
Please 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?*
- Yes
- No
- I do not plan on getting tested
In order 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 here.
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*
- Yes
- No
Remain out of work, 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.
- Positive
- Negative
With a positive test you should self-isolate yourself and follow the DHHS self-isolation guidance.
Are your symptoms improving?*
- Yes
- No
Have you taken fever reducing medications in the last 24 hours?*
- Yes
- No
You are cleared 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?*
- Yes
- No, 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.
Someone from Human Resources will be contacting you.
Household member is experiencing COVID like symptoms or has tested positive
Please 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?*
- Yes
- No
- They do not plan on getting tested
In order 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. Go to the DHHS COVID19 Testing Request page to find information and locations for testing..
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 result
- Yes - Negative result
- No - still waiting for their results
At 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.
Because your household member received a negative test you have been cleared to return to work.
You are not cleared to return to work, please re-submit this form once you receive their test results.
I have travel out of New England in the past 14 days
What 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?*
- Yes
- No
Upload a copy of your negative PCR COVID Test
You 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 Event
Do you have an approved FMLA event?*
- Yes
- No
Please contact hrmedical@dos.nh.gov immediately.
Non-work Related Injury
You have been cleared to return from work once you are able to.
Work Related Injury
A message has been sent to Human Resources and someone will be contacting you.
Other
What is the reason you are out?
Additional Information
Please provide any additional information

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About
- Who We Are
  Meet the Director
  
  Staff & Instructors
  
  History
  
  “First Alarm” Series
  
  Facilities
  Richard M. Flynn Training Facility, Concord
  
  Raymond S. Burton Training Facility, Bethlehem
  
  Northern EMS Field Office, Gorham
  
  Training Props
  
  Apparatus
  
  Training Grounds Coffeehouse
  
  Initiatives
  COVID-19
  
  Automated External Defibrillator Registry
  
  Organization
  Fire Standards & Training Commission
  
  Emergency Medical & Trauma Services Coordinating Board
  
  Medical Control Board
  
  Trauma Medical Review Committee
  
  Bureau of Certification and Support
  
  Bureau of Emergency Medical Services
  
  Bureau of Firefighter Training
News
Courses
- Courses
  Course Catalog
  
  Examinations
  
  Course & Examination Schedule
  
  Online Classroom
  
  Registration
  
  Course Registration
  Register Today
Licensing
Resources
- Student Resources
  Support
  
  Online Classroom
  
  Student Handbook
  
  Fire Certification Reciprocity
  
  How to Become a First Responder
  
  BLS Eligibility to Test Application
  
  First Responder Resources
  A Guide for New Fire Chiefs
  
  COVID-19
  
  EMS Accolades Report
  
  Licensing for Emergency Medical Services
  
  Patient Care Protocols (Version 8.0)
  
  Preplanned EMS Standby Coverage Best Practices
  
  Statewide Employment Opportunities
  
  Department Resources
  Academy Resource Request
  
  Department Information Update
  
  Department Training Request
  
  Instructor & Coordinator Resources
  Academy Resource Request
  
  Curricula
  
  EMS Instructor/Coordinator Resource Manual
  
  EMS Request for Examination
  
  Initial Course Request Form
  
  Instructor Application & Renewal
  
  Instructor Mentoring Program
  
  Instructor Policies
  
  Paramedic Interfacility Transfer Instructor Materials
  
  Practical Exam Evaluator Trainer Education
Events