This government document is issued by Respiratory Care Board for use in California
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https://www.google.com/url?client=internal-element-cse&cx=001779225245372747843:ds0ypfibnsy&q=https://www.rcb.ca.gov/enforcement/forms/ab_2138_second_modified_text.pdf&sa=U&ved=2ahUKEwjw89LPgb_xAhXGFXcKHTBqDrw4HhAWMAR6BAgEEAE&usg=AOvVaw0fmblRWifaeAq8YJGgGn7g