© UAE Certification Guidelines 2017

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DECLARATION:

You are required to make the following declarations:

1. I solemnly and sincerely declare that the information I have provided is true and correct to the best of my knowledge and belief. 2. I acknowledge that I may be required upon request by the CMSA to provide supporting evidence of the PTD activity claimed within this form. 3. I have read the Certification ApplicationGuidelines and checked that this PTD activity is a recognised and approved PTD activity by the CMSA as recorded within the said Guidelines. Please enter date (below) then print off Form A and add your handwritten signature. Enter the date you completed the PTD Form A i.e. day/month/ year.

SIGNATURE:

DATE:

PROFESSIONAL TRAINING AND DEVELOPMENT (PTD) FORM B

The PTD Form B is a summary record of the total sum of seventy two (72) hours of PTD activities and is a concise summation of each of the PTD activities as recorded within the PTD Form/s A. An applicant will only complete one (1) PTD Form B. The PTD Form B consists of the following information that is typed electronically into the form, then printed and signed by the applicant. All content must be typed into this form. Handwritten versions of the form will not be accepted by the CMSA.

PROFESSIONAL TRAINING AND DEVELOPMENT (PTD) FORM B APPLICANT DETAILS:

Please provide your title (Dr, Prof, Mr, Mrs, Ms),Surname and Given/First name. 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. 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. 1. I solemnly and sincerely declare that the information I have provided is true and correct to the best of my knowledge and belief. 2. I acknowledge that I must have accumulated a minimum of 72 hours of PTD activities as a pre-requisite to be eligible to apply for recognition as a Certified Case Manager™ pursuant to my nominated vocational pathway. Please enter date (below) then print off Form B and add your handwritten signature. Enter the date you completed the PTD Form A i.e. day/month/ year You are required to make the following declarations:

PTD NUMBER, TITLE AND TIME (HOURS/MINUTES) OF EACH INDIVIDUAL PTD ACTIVITY YOU HAVE CLAIMED ON FORM A: TOTAL TIME OF ALL PTD ACTIVITIES AS CLAIMED ON FORM A:

DECLARATION:

SIGNATURE:

DATE :

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

C E R T I F I E D C A S E M A N A G E R S U N I T E D A R A B E M I R A T E S

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 & A F F I L I A T E S 1 9 9 6

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. 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.