© Certification Application Guidelines

20

TITLE OF PTD ACTIVITY:

This is the title of the PTD activity and should include (as applicable) any associated codes for formal tertiary courses. This is the date that you completed the PTD activity and should include the day/month/year. Note: this date must be within three (3) years of your CCM application date or the PTD activity will be deemed ineligible. If the activity was completed over numerous days/months/years please record the commencement date i.e. day/month/year OR if completed intermittently [e.g. supervision/case conferences/ member of Specialist Interest Group] please list the individual dates and duration [hours/minutes] for each date. For example: • conference - state the conference host name/location. • training event - state the presenter name, company/institution and location (suburb, city/town, state). • supervision - state the supervisor name/position title/company name/location (suburb, city/town, state). • case conference - state the total number of attendees/ participants and location. • membership of, or contribution to, a Specialist Interest Group (SIG) - state name of SIG, number of participants and location. Important: due to legal parameters of confidentiality do not disclose nor record the names of attendees/participants [e.g. client/client representative/s] Please state relevancy of the PTD activity to your practice area/ role as it relates to Case Management. Please state the evidence that you can provide, if requested by the CMSA, of the PTD activity. For example, this may be a certificate of attendance, letter from your employer [e.g. HR record] or if you do not have any documentation supporting your claim please state, Statutory Declaration. Important: please do not submit any evidence (e.g. certificates, letters etc) with the PTD Form A. This will only be required if your application is audited by the CMSA at which time you will be given 28 days from the date of notice by the CMSA to submit evidence of the PTD activities you have claimed within this form. Please state the hours for the PTD activity in hours and/or minutes. For example: CMCT01 Case Management (National Certification) Competency Training = 6.5 hours of PTD activities. If the PTD activity exceeds the seventy two (72) hours please only record the PTD as seventy two (72) hours. For example: If you are claiming the completion (full of partial) of a diploma or certificate please only record the required minimum PTD hours i.e. 72 hours of PTD activities. Please add any additional information or comments in relation to this PTD activity that you consider relevant for the attention of the CMSA. Please provide details of the activity.

DATE OF PTD ACTIVITY:

DETAILS OF PTD ACTIVITY:

DESCRIPTION OF PTD ACTIVITY:

SUPPORTING EVIDENCE OF THE PTD ACTIVITY:

TOTAL TIME OF PTD ACTIVITY:

COMMENTS (OPTIONAL):

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 A U S T R A L I A & N E W Z E A L A N D

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

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.