Self-Declaration Form for Visitors to all ICONIX Locations in Canada
The health and safety of our customers, partners, and employees is and always will be a core value of our business, and we continue to take the necessary steps to ensure we are doing our part to keep the community healthy.

In response to COVID-19,  all visitors must complete this Self-Declaration Form on the same day of your scheduled visit and prior to entering any ICONIX facility.

Face Masks: Mask-wearing policies may vary by region. Please refer to protocols displayed at your local branch. A face mask is required in all indoor public spaces or anywhere physical distancing (6 feet / 2 meters) cannot be maintained.

Learn more: https://www.iconixww.com/wp-content/uploads/ICONIX-COVID19-Branch-Poster-Mandatory-Masks.pdf
Sign in to Google to save your progress. Learn more
Email *
Have you, or anyone you have been in close contact with, travelled internationally within the last 14 days and been advised to isolate or quarantine by local authorities? *
Are you, or anyone that you have been in close contact with, experiencing COVID-19 related symptoms (i.e. cough, sore throat, fever, difficulty breathing, etc.)? *
Have you been in close contact with anyone who has tested positive OR is presumed positive for COVID-19 within the past 14 days? *
Have you been advised to self-isolate by the local health authority? *
Applicable visitors must ensure that this form is completed in full and submitted to the ICONIX contact person prior to entrance at any ICONIX location. If a visitor fails to comply with these requirements or answers "YES" to any of the questions above, they will not be permitted on our site. *
Required
Any individual completing this form has an obligation to immediately notify their employer and their ICONIX contact if their status changes for any of the above questions and to self-isolate when required. *
Required
Full Name *
Company Name *
Form Completed Date *
MM
/
DD
/
YYYY
Which location are you visiting? *
Name of ICONIX contact you are visiting
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms