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Visitor Covid 19 Declaration Form
Quaker Houghton has implemented a simple health screening questionnaire prior to approving visitors to any of our locations. Your participation is important to help us take the necessary precautionary measures to protect everyone who works or may visit our locations. Thank you in advance for your cooperation.
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Visit Information
Date & Time of Proposed Visit
Date
Time
Region
*
North America
South America
Europe, Middle East, Africa
Asia, Pacific
Name of Facility
Visitor Information
Your Name
*
Your Email
*
Your Mobile / Office Number
*
Your Company / Organization
*
Your Quaker Houghton Contacts Name
*
Your Quaker Houghton Contacts Email
*
Health Screening Questionnaire
All visitors require pre-approval prior to visiting a Quaker Houghton location. Please answer the following questions and provide a copy to your QH contact. If the answer is yes to any of the following questions, access to the site will be denied and alternative communications will be set up.
Have you traveled internationally or been on a cruise ship or to a region/state with quarantine requirements within the past 14 days?
*
Yes
No
Have you had close contact with or cared for anyone diagnosed with or currently being evaluated for potential exposure to COVID-19 in the past 14 days?
*
Yes
No
Have you experienced any cold or flu-like symptoms (including fever (≥100.4°F/38°C), cough, sore throat, difficulty breathing or respiratory illness) within the past 14 days?
*
Yes
No
Please Enter Your Full Name as an e-Signature*
*
स्पष्ट हस्ताक्षर
Privacy Statement
*
I agree to the terms and conditions below
Note 1: If you plan to be on-site for consecutive days, please immediately inform your QH contact if any of your responses change. Note 2: Should there be a change in your health within 14 days after your visit, we would appreciate your notifying your QH contact. Quaker Houghton respects your privacy. The information collected on this form will be used solely for determining access rights to one of our locations and will not be retained past one month. If you have any concerns regarding privacy issues, please consult your Quaker Houghton contact or contact
[email protected]
. As always, it is your right to opt out of completing this form, however, access to our locations will be denied. As updates on COVID-19 become available, we want to assure you that we will continue to take appropriate preventative measures to ensure the safety of our colleagues and visitors. We will update these policies as the situation changes.
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