Self-Declaration Form for Visitors to All CENTRIX Locations

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The health and safety of our customers, partners, and employees is and always will be a core value of our business, and we will 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 CENTRIX 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.

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? * *

Yes

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.)? * *

Yes

Have you been in close contact with anyone who has tested positive OR is presumed positive for COVID-19 within the past 14 days? * *

Yes

Have you been advised to self-isolate by the local health authority? *

Yes

Applicable visitors must ensure that this form is completed in full and submitted to the CENTRIX contact person prior to entrance at any CENTRIX 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. *

I agree

Required

Any individual completing this form has an obligation to immediately notify their employer and their CENTRIX contact if their status changes for any of the above questions and to self-isolate when required. *

I agree

Required

Full Name *

Company Name *

Form Completed Date *

YYYY

Which location are you visiting? *

Name of CENTRIX contact you are visiting

A copy of your responses will be emailed to the address you provided.

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