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/document/form-e-mandatory-malpractice-questionnaire/download&sa=U&ved=2ahUKEwiNro6fi5mHAxW3_rsIHUXNAvo4MhAWegQIBhAB&usg=AOvVaw0UBH4gsAnRf96_5JkqOQMh&fexp=72519171,72519168