© Certification Application Guidelines

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Attachment 2 - Professional Training and Development (PTD) Form A - Page 2 of 2

Description of PTD activity: Please state relevancy of activity to your practice area/role as it relates to Case Management. Supporting evidence of the PTD activity: Please state the evidence that you can provide, if requested by the CMSA, of this PTD activity Total time of PTD activity: In hours and/or minutes. Comments (optional): Please add any additional information or comments in relation to this PTD activity that you consider relevant for the attention

of the CMSA. Declaration:

I solemnly and sincerely declare that the information I have provided is true and correct to the best of my knowledge and belief. I acknowledge that I may be required upon request by the CMSA to provide supporting evidence of the PTD activity claimed within this form. I have read the Certification Application Guidelines and checked that this PTD activity is a recognised and approved PTD activity by the CMSA as recorded within the said Guidelines.

Signature:

_________________________________________

Date:

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

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 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

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