This government document is issued by State Council on Developmental Disabilities for use in California
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https://www.google.com/url?client=internal-element-cse&cx=001779225245372747843:zpgtk_uj7l0&q=https://scdd.ca.gov/wp-content/uploads/sites/33/2020/04/COVID-health-passport-form-accessible.final-4.22.pdf&sa=U&ved=2ahUKEwjSgf3Qy8uHAxXXhP0HHZaOF1I4MhAWegQIAhAB&usg=AOvVaw1vU4lg44MaXlUpNVhgv9BO&arm=e