Visitor Covid 19 Declaration Form

Visit Information

Date & Time of Proposed Visit

日付

時間

Region *

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* *

署名をクリアー

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.