This government document is issued by Department of Public Health, Georgia Immunization Registry for use in Georgia
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https://www.google.com/url?client=internal-element-cse&cx=450907bf5042c4844&q=https://dph.georgia.gov/sites/dph.georgia.gov/files/Putative%2520Father%2520Registration%2520form%25202014%25200912.pdf&sa=U&ved=2ahUKEwi3prXGwfKKAxWDTKQEHTTNDs44UBAWegQIBRAB&usg=AOvVaw0nohvfESEXjj-KaHGm1jW8