Health Attestation

First Name*

Last Name*

Date of Your Appointment:*

Please specify below what Banking Center you will be visiting for your appointment.*

Select

I have taken my temperature, and it is normal or registered below 100.4 degrees.*

I attest.

I do not attest.

I am not experiencing any of the following symptoms identified by the CDC as potential COVID-19 symptoms:*

- fever or chills - cough - shortness of breath or difficulty breathing - fatigue - muscle or body aches - headache - new loss of taste or smell - sore throat - congestion or runny nose - nausea or vomiting - diarrhea

I attest.

I do not attest.

I have not traveled internationally within the last 14 days.*

I attest.

I do not attest.

I have not traveled outside of the lower-risk states identified by the Mass Health Department within the last 14 days*

Listing of lower risk states: https://www.mass.gov/info-details/covid-19-travel-order#lower-risk-states-

I attest.

I do not attest.

I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.*

I attest.

I do not attest.

I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non-contagious by state or local public health authorities.*

I attest.

I do not attest.

I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.*

I attest.

I do not attest.

I will notify the Bank if there are any changes to the answers provided above.*

I attest.

I do not attest.

If I am diagnosed with Covid 19 within five days of my appointment at Cape Cod 5 I will inform Cape Cod 5 by calling 508-247- 2268.*