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/about_us/forms/rcb_bvnpt_statement_july_2019_revised.pdf&sa=U&ved=2ahUKEwjnt76hhb_xAhXEpIsKHZljCUk4KBAWMAl6BAgGEAE&usg=AOvVaw2UepF1INMGuQcljgvjHk0r