Self-Declaration Form for Visitors to All CENTRIX Locations
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
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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 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. *
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. *
Full Name *
Company Name *
Form Completed Date *
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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