Self-Declaration Form for Visitors to all ICONIX Locations in Ontario
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, all visitors must complete this Self-Declaration Form on the same day of your scheduled visit and prior to entering any ICONIX 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.

Learn more: https://www.iconixww.com/wp-content/uploads/ICONIX-COVID19-Branch-Poster-Mandatory-Masks.pdf
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Email *
Are you experiencing any of the following new-onset or worsening symptoms? (Symptoms should not be chronic or related to other known causes or conditions) - Fever or chills; difficulty breathing; cough; sore throat/trouble swallowing; runny/stuffy nose or nasal congestion; decrease or loss of smell or taste; nausea, vomiting, diarrhea, abdominal pain; not feeling well, extreme tiredness, sore muscles?
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In the last 14 days, have you or anyone you live with travelled outside of Canada? *
In the last 14 days, has a public health unit identified you as a close contact of someone who currently has COVID-19? *
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? *
Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? *
Applicable visitors must ensure that this form is completed in full and submitted to the ICONIX contact person prior to each scheduled entry at any ICONIX location. If a visitor answers “NO” to the above questions (1-3), 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 ICONIX worksite and will be advised to immediately self-isolate and contact their health care provider or Telehealth Ontario (1-866-797-0000) 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 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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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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