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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.
COPYRIGHT © 2017 Case Management Society of Australia and New Zealand and Affiliates (CMSA)
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Attachment 2 - Professional Training and Development (PTD) Form A – Page 1 of 2
CERTIFIED CASE MANAGER™
- PROFESSIONAL TRAINING & DEVELOPMENT FORM PART A
TO THE APPLICANT
The information being sought in this form is for the
purpose of verifying your 72 hours of Professional Training
and Development (PTD) undertaken in the last 3 years and
backdated from the date of your online application to the
CMSA. Activities undertaken must be related to Case
Management and specific to your practice area/role as it
relates to case management (practical or theoretical). Full
details of approved PTD activities are listed within the
Certification Application Guidelines.
As part of the CMSA’s ongoing Quality Assurance of
Certified Case Managers
™
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 separate form must be completed for each PTD activity
until you have accrued the minimum total of 72 hours of
PTD. All copies of Form A must be certified prior to being
submitted online (along with a summary of all of your PTD
activities within Form B) 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.
Applicant details:
Title
(Dr, Prof, Mr, Mrs, Ms):
SURNAME:
GIVEN/FIRST name:
PTD Number:
Please insert a number for each
time you complete this form. For
example if this is the first PTD
activity you are claiming please
insert “1”, The next time you
complete Form A you should insert
“2”, then “3” etc in numerical order
for each Form A you complete.
Title of PTD activity:
Date of PTD activity:
Details of PTD activity:
Presenter:
Company: