Welcome,
kubik requests that you complete this Visitor Registration before coming into our location.
This helps all of us keep our workplace safe from COVID-19 and to assist us in our response efforts if an infection is detected.
First Name
Last Name
Phone Number
Email
Date of visit?
Start time of your visit
Company Name
License Plate
Reason For Visit?
Do you have any of the following (new or worsening):
Fever?
Yes
No
Cough?
Yes
No
Difficult Breathing?
Yes
No
Sore Throat, Trouble Swallowing?
Yes
No
Runny Nose?
Yes
No
Loss of Taste or Smell?
Yes
No
Not Feeling Well?
Yes
No
Nausea, Vomiting, Diarrhea?
Yes
No
Have you been in close contact with someone who has confirmed COVID-19 in the past 14 days without wearing appropriate PPE?
Yes
No
Have you returned from travel outside Canada in the past 14 days?
Yes
No
Send
We Have Received Your Guest Registration.
If
you answered
YES
to any of the questions in our
COVID-19
Screener. Please
DO NOT
come to our facility.
SELF-ISOLATE
right away and Call Tele-Health or your health care provider, to find out if you need a test.
