© 2013 Associate Fellow Application Guidelines

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

ASSOCIATE FELLOW - 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 Associate Fellow 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 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

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

SURNAME:

Applicant details:

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. Total time of all PTD activities as claimed on Form A: Please record the total sum of hours and/or minutes for all PTD activities you have recorded and claimed on each Form A. Please note you are required to have accumulated a minimum of 72 hours of PTD in the last 3 years to support your application.

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

Associate Fellow Members (AFCMSA) of the Case Management Society of Australia & New Zealand (CMSA) adhere to the CMSA National Standards & National Code of Ethics for Case Management in all their day-to- day professional interactions with colleagues, the community, clients & /or representatives, key stakeholders & employer thus contributing to the veracity, integrity & fidelity of the profession of case management.