This government document is issued by Department of Community Health for use in Georgia
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https://www.google.com/url?client=internal-element-cse&cx=450907bf5042c4844&q=https://dch.georgia.gov/sites/dch.georgia.gov/files/ATTACHMENT%2520H%2520-%2520Immigration%2520and%2520Security%2520Form.pdf&sa=U&ved=2ahUKEwi3p-2uzJaHAxVJSEEAHfh0ByM4HhAWegQICRAB&usg=AOvVaw1NqgEK8JzDGoypAGyYRabw&fexp=72519171,72519168