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.
Please select your region: ---North AmericaEurope, Middle East, AfricaAsia, PacificSouth America
Your Mobile/Office Phone Number: (please only insert numbers, not dashes or other characters)
Your Quaker Houghton Contact:
The Email Address for Your Quaker Houghton Contact:
Name of Facility that You are Visiting:
Date of Proposed Visit:
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.
1. Have you returned from visiting any of the following countries: China, Japan, Singapore, South Korea, Iran or Italy, within 14 days of your planned visit? ---YesNo
2. 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? ---YesNo
3. Have you experienced any cold or flu-like symptoms (including fever (100°F/38°C), cough, sore throat, difficulty breathing or respiratory illness) within the past 14 days? ---YesNo Please write your full name as an e-signature
Please write today's date for your e-signature
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@example.com. 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.
Please check the box to confirm you agree with our above privacy statement.