This government document is issued by Health Commission for use in Los Angeles, CA
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https://www.google.com/url?client=internal-element-cse&cx=009475663812252016293:bzt7btqbbya&q=https://clerk.lacity.org/sites/g/files/wph1491/files/2021-03/Witness_Statement_Form_0.pdf&sa=U&ved=2ahUKEwijpcDgzPP8AhV157sIHU8pAY44WhAWegQIABAB&usg=AOvVaw38QU1jeSP6wIwDveUz0fGW