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/document/publication/157251033revhospitalselfreportform342010pdf/download&sa=U&ved=2ahUKEwj0_eqN0JaHAxVnk_0HHW--DY04PBAWegQIBxAB&usg=AOvVaw1VqwSkOOV3RYzBzwjdquaM&fexp=72519171,72519168