Self-Declaration Form for Visitors to all ICONIX Locations in the United States
Email address *
Purpose
The health and safety of our customers, partners, and employees is and always will be our top priority, 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, effective March 20, 2020, we are practicing social distancing by restricting the flow of visitors inside our facilities. If you require coming into our location, we will need each visitor to complete the Self-Declaration Form below.
Have you, or anyone you have been in direct contact with, traveled and returned to the US within the past 14 days. *
Have you, or anyone you have been in direct contact with, experienced flu-like symptoms (cough, sore throat, fever, difficulty breathing etc.) in the past five (5) days? *
Have you, or anyone you have been in direct contact with, been advised to self-isolate within the past five (5) days? *
Have you, or anyone you have been in direct contact with, tested positive to COVID-19 within the past 14 days? *
This form must be completed in full and submitted prior to any customer, vendor, their employees, subcontractors, and delivery suppliers arriving at any ICONIX location. Failure to do so will mean you will not be allowed entry to our site. If you have answered "Yes" to any of the above questions, you will not be allowed entry to 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 *
Your answer
Company Name *
Your answer
Form Completed Date *
MM
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DD
/
YYYY
Which location are you visiting today? *
Your answer
Name of ICONIX contact you are visiting today
Your answer
A copy of your responses will be emailed to the address you provided.
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