© ANZ National Certification Learn More Booklet

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Attachment 3 - Professional Training and Development (PTD) Form B – Page 1 of 2

CERTIFIED CASE MANAGER™ - PROFESSIONAL TRAINING & DEVELOPMENT FORM PART B

The information being sought in this form is a summary of all of the Professional Training and Development (PTD) activities you have claimed in each Form A. Its purpose is to verify you have accumulated the minimum 72 hours of pre-requisite PTD for your Certified Case Manager™ application, by cross referencing the details in Form B to the details you have recorded individually in Form A. It is the responsibility of the applicant to record, calculate and check the total hours of the PTD activities claimed on this form. It is recommended that you seek assistance from another individual to check the accuracy of your final calculations. It is important that you understand that the Society will conduct random audits of Certified Case Manager ™ applications and accordingly you may be contacted by a representative of the CMSA seeking evidence of the information you have claimed within this form. If you are audited you will be given 28 days from the date of notice by the CMSA to submit evidence of your PTD activities. A copy of Form B must be certified prior to being submitted online. You must submit Form A for each individual PTD activity and Form B as a summary of all your PTD activities to the CMSA. Applications submitted without either Form A or Form B will be considered incomplete and will not be accepted by the CMSA. Please complete, print and sign this form. All content must be typed into this form. Handwritten versions of the form will not be accepted by the CMSA.

TO THE APPLICANT

Applicant details:

Title (Dr, Prof, Mr, Mrs, Ms):

SURNAME:

GIVEN/FIRST name:

PTD number, title and time (hours/minutes) of each individual PTD activity you have claimed on Form A. Please number and list all of the PTD activities you have entered individually onto Form A, including the individual hours and/or minutes for each PTD activity.

COPYRIGHT © 2017 Case Management Society of Australia and New Zealand and Affiliates (CMSA)

C A S E M A N A G E M E N T S O C I E T Y O F A U S T R A L I A & N E W Z E A L A N D 1 9 9 6

C E R T I F I E D C A S E M A N A G E R A U S T R A L I A & N E W Z E A L A N D

The Case Management Society of Australia and New Zealand and Affiliates (CMSA) Certification sets the benchmark of excellence in case management. Certified Practising Case Managers™ (CPCM) and Certified Case Managers (Non Practising)™ (CCMNP) adhere to the CMSA National Standards and National Code of Ethics for Case Management and are recognised for their advanced education, experience, knowledge and skills by their colleagues, consumers and employers.