Self-Declaration Form for Visitors to all CENTRIX Locations in BC
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, and in compliance with the Provincial Health Officer's order, all visitors must complete this Self-Declaration Form prior to entering any CENTRIX facility. This screening process will be required of any workers or essential visitors entering CENTRIX workplaces.

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.centrixcs.com/wp-content/uploads/2020/10/Steps-We%E2%80%99re-Taking-to-Address-COVID-19-CENTRIX.pdf
Email address *
Are you experiencing any of the following new-onset symptoms - Fever or chills; new or worsening cough; stuffy or runny nose; sore throat/trouble swallowing; diarrhea; difficulty breathing; nausea and/or vomiting; fatigue; muscle aches; loss of appetite; chills; headache; loss of sense of smell? *
Have you travelled outside of Canada, including the United States, within the past 14 days? *
Have you been in close contact with someone who has a confirmed COVID-19 diagnosis within the last 14 days? *
Have you been told to self-isolate in accordance with Public Health Directives? *
Applicable visitors must ensure that this form is completed in full and submitted to the CENTRIX contact person prior to each scheduled entry at any CENTRIX location. If a visitor answers “NO” to the above questions, they will be authorized access to the worksite. If a visitor answers “YES” to any of the above questions, they will be restricted from accessing the CENTRIX worksite and will be advised to immediately self-isolate and contact their health care provider or 811 to find out whether or not a COVID-19 test is required. *
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. *
Required
Full Name *
Company Name *
Form Completed Date *
MM
/
DD
/
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.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy