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.

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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. *
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. *
Full Name *
Company Name *
Form Completed Date *
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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