Self-Declaration Form for Visitors to all ICONIX Locations in the United States
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, effective March 20, 2020, all visitors must complete this Self-Declaration Form on the same day of your scheduled visit and prior to entering any ICONIX facility.

Effective immediately: To protect you and our employees, a face mask/covering is required while indoors and anywhere physical distancing cannot be maintained (6’ or 2 meters).

Learn more: https://www.iconixww.com/wp-content/uploads/ICONIX-COVID19-Branch-Poster-October2020-Mandatory-Masks.pdf
Email *
Have you, or anyone you have been in close contact with, traveled outside of the United States within the past 14 days? *
Are you, or anyone that you have been in close contact with, experiencing flu-like 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 *
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DD
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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.
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