Daily Health Screening Questionnaire
This health questionnaire MUST be completed by each family and faculty member every school day prior to coming to school.

NOTE: If you have passed your health screening, but are experience issues with submitting the survey, please email hssoffice@hsseg.com with the following message: "I attempted to submit the health screening questionnaire online and was unsuccessful. I am answering NO to every question on the screening."
Email *
Parent/Staff Member First Name *
Parent/Staff Member Last Name
Names of All Students
Has the student(s) or faculty member presented with any of the following symptoms: Fever (temperature over 100.0 F) without having taken any fever reducing medication, Loss of Smell or Taste, Muscle Aches, Sore Throat, Cough (without use of cough suppressant medication), Shortness of Breath, Chills, Runny nose/congestion/cold symptoms, Headache/blurred vision/dizziness, Diffuse rash, redness, blemishes or blotches on the skin? *
Has the student(s) or faculty member experienced any gastrointestinal symptoms such as Nausea/vomiting or diarrhea? *
Has your student(s) or faculty member, or has any member of your household, or anyone you have been in close contact with, been diagnosed with COVID-19, or been placed on quarantine for possible contact with COVID-19 during the past 14 days? *
Has your student(s) or faculty member, or any member of your household, been asked to self-isolate or quarantine by medical professional or a local public health official? *
Is your student(s) or faculty member awaiting the results of a COVID test? *
If you answered YES to any question above, please indicate which student(s) or members of your family the YES applies to and add any relevant notes for our school office concerning why you answered YES.
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Holy Spirit School.