This government document is issued by Composite Medical Board for use in Georgia
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https://www.google.com/url?client=internal-element-cse&cx=450907bf5042c4844&q=https://medicalboard.georgia.gov/sites/medicalboard.georgia.gov/files/imported/GCMB/Files/1106%2520Form%2520B11%2520July%25202010.pdf&sa=U&ved=2ahUKEwjF4cr3vJeHAxVF2wIHHYWSBeo4HhAWegQICBAB&usg=AOvVaw3PXMfbaiiyxO4YGZMalmhV&fexp=72519171,72519168