Health Self-Assessment Screening
This questionnaire is used to assess your ability to be on the Winston School campus according to the guidelines published by the San Diego County Department of Public Health and California Department of Education. Please complete a new form each day you plan to be on campus.
Please enter your first and last name.
Are you currently experiencing any of the following symptoms (check all that apply)?
Fever or chills
Shortness of breath or difficulty breathing
Muscle or body aches
New loss of taste or smell
Congestion or runny nose
Nausea or vomiting
I am not experiencing any of these symptoms.
Please take your temperature prior to coming on campus. Do you currently have (or have you had) a temperature of 100.4ºF or above? Within the past 24 hours?
Have you traveled outside of the United States within the past 14 days? Please review the CDC travel restriction website:
Have you or anyone in your immediate family received a positive test for COVID19 within the past 14 days?
Thank you for taking this health self-assessment screening. If you answered "yes" to any question, DO NOT enter the Winston School campus. Please contact your healthcare provider for further guidance. ALL staff and visitors must adhere to all posted rules and regulations.
Please remember to maintain 6 feet of social distance, wear your mask as directed, and practice extreme hygiene. You may direct questions to Kim Kanetis at
Send me a copy of my responses.
Never submit passwords through Google Forms.
This form was created inside of The Winston School.