2021/2022 Student Pre-screening COVID-19 Questionnaire
All parents, children and essential visitors will need to complete a daily health self-check by answering the questions listed below and by taking their own temperatures each day prior to entering the school or being on the school property.  

A parent or guardian is responsible for completing the daily screening on behalf of their son(s).  In the space requesting an email, please enter your son's school email so he is able to receive a copy of the survey results to show upon arrival on campus.  If you wish to maintain a copy of the results for your own record, forward a copy of the results email to your personal email.    

If you have any questions regarding the completion of this survey, please contact Mrs. Susan Ramondelli (School Nurse) at sramondelli@salesianhigh.org 
Sign in to Google to save your progress. Learn more
Email *
What is today's date? (mm/dd/yyyy) *
What is the student's name? (First name and Last name) *
What is your son's current grade? *
In the past 10 days, have you or anyone in your household been tested for the COVID-19 virus, or been in contact with someone who has been tested for the COVID-19 virus? *
If you, or anyone in your household, has been tested for COVID-19 or been in contact with someone who has been tested, what was the result?  (If you answered yes to the previous question, you are required to stay at home until contacted by the school nurse or DOH) *
Have you, or anyone in your household, come in close contact (within 6 feet) with someone who has a suspected or confirmed COVID-19 diagnosis in the past 10 days? *
Before departing your residence, was a temperature screening performed today? *
Are you, or anyone in your household, currently experiencing OR recently experienced in the past 10 days fever (greater than 100.0 F or 37.7 C) OR symptoms including, but not limited to: Chills, Cough, Shortness of breath, Headache, Loss of taste or smell, Sore Throat, Runny nose, Nasal Congestion, Diarrhea, Nausea/Vomiting, Fatigue, or Muscle Aches? *
Within the last 10 days, have you or anyone in your household, been asked to self-isolate or quarantine by a doctor or public health official? *
Please provide the name of the Parent/Guardian who filled out the above information? *
By entering your initials in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge. *
A copy of your responses will be emailed to the address you provided.
Clear form
Never submit passwords through Google Forms.
This form was created inside of Salesian High School. Report Abuse