This government document is issued by Department of State Hospitals (DSH) for use in California
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https://www.google.com/url?client=internal-element-cse&cx=001779225245372747843:zqiqummuqzk&q=http://www.dsh.ca.gov/patton/internships_training/docs/RECENCY_of_EDUCATION_Form.pdf&sa=U&ved=2ahUKEwi7-aHWz5HyAhUpi8MKHR19B4c4WhAWMAV6BAgHEAE&usg=AOvVaw2c2liOWm03gRAvizBrsmbG