This government document is issued by Department of Health for use in Pennsylvania
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https://www.google.com/url?client=internal-element-cse&cx=007572080359491747877:-o2sxg2obgu&q=https://www.health.pa.gov/topics/Documents/Programs/Violence%2520and%2520Injury%2520Prevention/Anonymous%2520Reporter%2520Form%2520and%2520Guide%2520-%2520fillable.pdf&sa=U&ved=2ahUKEwjhqb_VsdD8AhXbQEEAHdr1B904MhAWegQIAxAB&usg=AOvVaw1klz7LjnS6dpgKgMKQkOs0