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/2_Supervisor%2520instructions%2520Staff%2520Infection%2520Control%2520Screen.docx&sa=U&ved=2ahUKEwihhODUrfGFAxXNh_0HHROvCbs4FBAWegQIAxAB&usg=AOvVaw1qa2gBFQ7qcl7g5ZCaG87Z