This government document is issued by Drug and Alcohol Programs for use in Pennsylvania
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https://www.google.com/url?client=internal-element-cse&cx=007572080359491747877:ug3qpcrqbm4&q=https://www.ddap.pa.gov/Other%2520Forms/Instructions%2520for%2520completing%2520Infection%2520Control%2520Screen.docx&sa=U&ved=2ahUKEwjU38P-mfGFAxXchf0HHWZDDDY4FBAWegQIABAC&usg=AOvVaw0Ns-zVL8A7W6_NhUuYVGUD