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FELLOW APPLICATION GUIDELINES

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ethical | enabling | challenging | sustainable

CONTENTS

The Fellow Application Guidelines . ....................................................................................................... 1

Applying to be a Fellow .......................................................................................................................... 1

Stages of the Application Process .......................................................................................................... 2

The Online Application Form ................................................................................................................... 2

Checklist of Evidence Required to Support an Application ................................................................... 5

Certified Copies of Original Documents ................................................................................................ 5

Statutory Declarations ............................................................................................................................ 6

Auditing of Applications .......................................................................................................................... 6

Vocational Case Management Experience . ............................................................................................ 6 Employment Verification Form............................................................................................................... 6

Professional Training and Development (PTD) Activities ...................................................................... 7 Form A and Form B .............................................................................................................................. 7 Examples of PTD Activities..................................................................................................................... 7

Professional References ........................................................................................................................... 7 Referee Form 1 and Referee Form 2....................................................................................................... 7

Compliance with the National Standards and National Code of Ethics for Case Management ........ 8

Investiture Ceremony (optional) ............................................................................................................ 8

Fees ............................................................................................................................................................ 8 Payment of Fees.................................................................................................................................... 8 Schedule of Fees. .................................................................................................................................. 9

Appeals Regarding an Application .......................................................................................................... 9 CMSA Appeals Policy. ........................................................................................................................... 9

Privacy of Your Information .................................................................................................................... 9

Attachments . ......................................................................................................................................... 10 Employment Verification Form – Example Only ................................................................................... 11 Professional Training and Development (PTD) Form A – Example Only ................................................. 13 Professional Training and Development (PTD) Form B – Example Only ................................................. 15 Referee Form 1– Example Only ........................................................................................................... 17 Referee Form 2 – Example Only .......................................................................................................... 19

THE FELLOW APPLICATION GUIDELINES The Fellow Application Guidelines (herein referred to as “the Guidelines”) are designed to provide you with details pertaining to the application process and transparency of the information you are required to submit to the CMSA in your application for recognition as a Fellow (FCMSA). It is an obligatory requirement for each candidate to read in full all of the information within the Guidelines prior to submitting their online application to the CMSA. The rationale behind this stipulation is that the candidate is fully prepared and has all the information to hand for the successful completion of their online application. For all questions and or queries related to an application the candidate should on the first occasion refer to the Guidelines, for detailed information prior to contacting the CMSA. APPLYING TO BE A FELLOW To be eligible to apply for an affiliate membership a candidate must demonstrate they have the advanced knowledge, skills, experience, and/or qualifications as outlined within the pre-requisite requirements pursuant to a Fellow as follows: • minimum of ten (10) years FTE (18240 hours) vocational case management experience, including practical application (i.e. case management practice and/or the management/supervision of case managers or case management programs) or theoretical application (i.e. case management education or research). The individual must have 12 months (1824 hours) experience in the last three (3) years;

• seventy two (72) hours of Professional Training and Development activities in the past three (3) years;

• Certificate of Attainment for CMCT01 Case Management (National Certification) Competency Training; and

• two (2) signed professional references.

All applications for recognition as a Fellow must be submitted to the CMSA online. The CMSA will not accept nor process any applications (either full or part thereof) received by mail, email or facsimile. Accordingly, you will be required to provide certified copies (as outlined within the Guidelines) of all original documents as evidence in support of your application. For these documents to be submitted to the CMSA at the time of your online application it is important that you have access to a scanned copy of each and every certified document to attach (i.e. upload from your personal computer). If you are not “computer savy” the CMSA recommends that you seek assistance from another individual or your employer to support you in completing your online application. The CMSA regrets to inform you that we cannot provide you with this support at the time of your online application.

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Fellow Members (FCMSA) 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.

STAGES OF THE APPLICATION PROCESS There are four (4) Stages to obtaining a Fellow membership as follows:

Stage One

Application is submitted online to the CMSA. Fees paid in full upon application.

Stage Two (Week 1–3)

• Application is received by the CMSA and the candidate is notified in writing

• Application is appraised by the CMSA

• If an application is deemed incomplete or insufficient information has been provided the candidate is contacted by the CMSA and advised of the deficits and asked to provide this information

Stage Three (Week 4-6)

• Application is approved by the CMSA and the candidate is notified in writing

Stage Four (Week 6-8)

Successful candidate receives Fellow Membership of the CMSA including the following:

• Full CMSA Membership benefits

• Use of the post nominals FCMSA

• FCMSA testamur (parchment)

• Optional Investiture Ceremony – all associated costs to be incurred by the Fellow Member (e.g. hire of gown, sash, travel etc)

Delays in Processing Applications

The timeframes within the application process (as outlined above) should be used by the candidate as a guide only. Whilst the CMSA will endeavour at all times to process your application pursuant to these guidelines there may be circumstances (foreseeable or non foreseeable) which arise resulting in a delay to your application.

These may include:

• Incomplete or insufficient application submitted by candidate.

• Variations to the business hours and operations of the CMSA, including Public Holidays, temporary closure of the CMSA office or limitations on CMSA resources i.e. staff leave or absences or high volume of applications.

• Technical issues affecting access to the CMSA website, internet, client management systems or software.

• Delays in delivery or receipt of products from suppliers to the CMSA.

• Delays in receipt of products to the candidate from Australia Post.

THE ONLINE APPLICATION FORM Each candidate will be required to submit information, and certified scanned copies of evidence, at the time of the online application. It is important that you read and prepare the information and evidence (attachments) in readiness for your online application. Where “attachments” are requested you are required to upload a scanned copy or PDF copy of the document requested. Please ensure you have these copies available to access at the time of your online application. It is important you understand that you must provide all information as requested in order for your application to be processed by the CMSA. Omitting (by default) any required information as listed below will render your application invalid by the CMSA and you will be required to provide this information in order for your application to be appraised.

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Fellow Online Application Form

Title

First Name

Last Name

Agency

Position Title

Department Name

Business Address Line 1

Business Address Line 2

Business Address Line 3

Suburb

State

Postcode

Postal Address Line 1

Postal Address Line 2

Postal Address Line 3

Suburb

State

Postcode

Business Phone

Mobile

Primary Email Address

Secondary Email Address

Date of Birth

Qualifications (please list) I have attained the minimum 10 years FTE (18240 hrs) vocational case management experience. Please note you must have practised for 12 months (1824 hrs) in the last 3 years Please attach the Employment Verification Form signed by your employer & Certified OR if Self Employed please attach a Statutory Declaration.

1. Employment Verification Form 2. Self Employed (Statutory Declaration)

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Please attach a copy of your Curriculum Vitae (CV)

Please attach a scanned copy of all PTD Form A as a record of your PTD activities (each copy must be signed and Certified). Note you must scan a copy of Form A into one (1) PDF document only. Multiple uploads are not available. Please attach a scanned copy of PTD Form B as a summary of all 72 hrs of PTD activities (copy must be signed and Certified). Please attach your Certificate of Attainment CMCT01 Case Management (National Certification) Competency Training Please attach Referee Form 1 (copy must be signed and Certified) Please attach Referee Form 2 (copy must be signed and Certified) I have submitted the following evidence as a mandatory requirement of my application and acknowledge that failure to do so will render my application incomplete for the purpose of assessment by the CMSA. I solemnly and sincerely commit to read, understand, utilise and apply the CMSA National Code of Ethics within all my professional interactions as a member of the CMSA. I solemnly and sincerely commit to read, understand, utilise and apply the CMSA National Standards within all my professional interactions as a member of the CMSA. I have read and consent to the CMSA Privacy Policy (see www.cmsa.org.au) and understand how it relates to the use of my personal information. I have read, acknowledge and agree to abide by the CMSA Constitution and By-laws I declare the above to be true and correct.

1. Qualifications (listed only) 2. Employment Verification Form OR Statutory Declaration 3. Curriculum Vitae (CV) 4. Professional Training and Development (PTD) Forms (Form A & Form B) 5. Certificate of Attainment CMCT01 Case Management ( N a t i o n a l C e r t i f i c a t i o n ) C o m p e t e n c y T r a i n i n g

6. Referee 1 7. Referee 2

I hereby agree

1. Yes 2. No

I hereby agree

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CHECKLIST OF EVIDENCE REQUIRED TO SUPPORT AN APPLICATION The following is a checklist of the evidence (“attachments”) that you must submit to the CMSA at the time of your online application. Please check that you have all the required “attachments” available on your personal computer to submit to the CMSA when you apply online.  Employment Verification Form or Statutory Declaration Form (if self employed) copy must be signed by your employer and certified  A PDF copy of your Curriculum Vitae (CV)  Professional Training and Development (PTD) Forms A and Form B copies must be signed by applicant and certified CERTIFIED COPIES OF ORIGINAL DOCUMENTS The following forms must be completed and certified copies submitted to the CMSA as part of your online application. These forms are available online at www.cmsa.org.au on the Membership Categories page of the website. Please download and save a copy to your personal computer. Please note all information must be typed into the form, saved and then printed prior to being signed and certified. You must then scan the certified copy and save a copy to your personal computer in readiness to attach to your online application. Hand written copies will not be accepted by the CMSA.  Referee Form 1 copy must be signed by referee and certified  Referee Form 2 copy must be signed by referee and certified  Certificate of Attainment official PDF copy issued by CMSA

1. Employment Verification Form 2. Professional Training and Development (PTD) Form A (Individual PTD activity) 3. Professional Training and Development (PTD) Form B (Summary of PTD activity)

4. Referee form 1 5. Referee form 2

Please note where a candidate is self employed they must submit a Statutory Declaration in lieu of an Employment Verification Form. This should include details of your vocational case management experience (practical or theoretical) with dates and total FTE equivalent hours for term of employment. You should refer to a copy of the Employment Verification Form when drafting your Statutory Declaration to ensure you provide the CMSA with the full particulars of your current and past employment details.

Getting documents certified.

Where a copy of a document (i.e. form) is required to be certified, it must be certified by one of the following individuals:

• Commissioner for Declarations • Commission of Oaths • Judge • Justice of the Peace • Magistrate • Police Officers in Victoria, Tasmania and Western Australia • Practising lawyer • Registrar/Deputy Registrar of the Magistrates Court in Victoria

Note: Medical Practitioners, pharmacists, registered nurses etc are not eligible to certify documents unless they are also one of the individuals on the above list provided.

When certifying documents, the above individual needs to include the following or similar statement on each page of the document:

1. I certify that this is a true copy of the original document. Signature: Name: Designation: Date: Number:

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Documents incorrectly certified will not be accepted by the CMSA.

To find a Justice of the Peace in Australia, go to http://australia.gov.au/topics/law-and-justice/justices-of-the-peace or New Zealand, go to http://www.jpfed.org.nz/Find+a+JP.html STATUTORY DECLARATIONS If you are required to submit a Statutory Declaration in lieu of an Employment Verification Form (for those candidates who are self employed) these are available from each state and territory or from the Australian Government Attorney General’s Department. http://www.ag.gov.au/STATDEC or New Zealand residents please go to http://www.jpfed.org.nz/What+Can+a+JP+Do+For+Me/ statutory+declaration.html AUDITING OF APPLICATIONS As part of the CMSA’s ongoing quality assurance of Affiliate Members the Society will conduct random audits of applications, including authenticating information provided by the candidate or on the candidate’s behalf within the Employment Verification Form, Professional Training and Development (PTD) Form A and Form B, Referee Form 1 and Referee Form 2. Should you be audited you, and/or individuals submitting information in support of your application, will be given 28 days, from the date of notice issued by the CMSA, to verify, clarify and/or substantiate all claims. This may include a request for evidence (e.g. certified copies of certificates, letters of verification etc) of claims you have made as to your Professional Training and Development activities. VOCATIONAL CASE MANAGEMENT EXPERIENCE Employment Verification Form All candidates must complete and submit a certified copy of the Employment Verification Form as evidence of their vocational case management experience (practical or theoretical). This form is available online at www.cmsa.org.au on the Membership Categories page of the website. Please download and save a copy to your personal computer. Please note all information must be typed into the form, saved and then printed prior to being signed and certified. You must then scan the certified copy and save a copy to your personal computer in readiness to attach to your online application. Hand written copies will not be accepted by the CMSA. Please note you must demonstrate that 12 months (1824 hours) Full Time Equivalent (FTE) practice (practical or theoretical) of your total hours has occurred in the past 3 years. This compulsory FTE is based on 38 hours per week over 48 weeks. • Provide a copy of the Fellow Application Guidelines to the individual completing the form. • Download and provide a copy of the form in Microsoft Office Word to the individual completing the form. • Provide the individual with the CMSA contact details should they have any questions related to completing the form. • Check the completed form for any errors or omissions prior to having it certified. If you are self employed and are submitting a Statutory Declaration in lieu of an Employment Verification Form it is your responsibility to: • Download a Statutory Declaration form from the Australian Government Attorney General’s Department. http://www.ag.gov.au/ STATDEC or New Zealand http://www.jpfed.org.nz/What+Can+a+JP+Do+For+Me/statutory+declaration.html • Prepare the content in full by referring to the Employment Verification Form. The CMSA will not contribute to this process and recommends you seek assistance from another individual in the drafting and review of the content. • Include details of your current and past vocational case management experience (practical or theoretical) with dates and total FTE equivalent hours for term of employment. • Check the completed Statutory Declaration for any errors or omissions prior to having it certified. If you are submitting an Employment Verification Form it is your responsibility to:

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PROFESSIONAL TRAINING AND DEVELOPMENT (PTD) ACTIVITIES Form A and Form B

Pursuant to the pre-requisite requirement of an online application a candidate is required to submit evidence of a minimum of seventy two (72) hours of Professional Training and Development (PTD) activities in the past three (3) years. You are required to use the CMSA resources and/or a combination of CMSA and other resources to meet the minimum level of PTD. The CMCT01 Case Management ( N a t i o n a l C e r t i f i c a t i o n ) C o m p e t e n c y T r a i n i n g should be included within your r ecord of PTD activities. It is essential that you complete a Professional Training and Development Form A for each individual PTD activity and a Professional Training and Development Form B as a summary of the total sum of seventy two (72) hours of PTD activities. As it is your responsibility to record, calculate and check the total hours of claimed PTD activities, the CMSA recommends you seek assistance from another individual to check the accuracy of your calculations. It is a compulsory requirement that you complete and submit both forms to the CMSA with your application. An application received without either Form A or Form B will be deemed incomplete and will not be accepted by the CMSA. Both PTD forms are available online at www.cmsa.org.au on the Membership Categories page of the website. Please download and save a copy to your personal computer. Please note all information must be typed into the form, saved and then printed prior to being signed and certified. You must then scan the certified copy and save a copy to your personal computer in readiness to attach to your online application. Hand written copies will not be accepted by the CMSA. As you will be completing numerous copies of Form A as a record of each PTD activity you are required to collate and scan all completed, signed and certified copies of Form A into one (1) PDF document . Depending on the number of PTD activities this will result in one (1) large scanned file to be attached to your online application. Please do not scan forms separately as multiple uploads will not be available when you complete your online application . The following are examples of activities that qualify as PTD activities: • Conferences, congresses, conventions, courses, forums, lectures, seminars, workshops and other professional educational activities presented by the CMSA and/or under the auspices of academic institutions, commercial establishments or other professional bodies. • Educational activities provided by the candidate’s employer or practice entity, either in-house or externally by individuals or organisations engaged by the employer and relevant to the candidate’s practice area or case management role. • Tertiary courses presented by educational institutions. • Self-study courses, training and programs facilitated by the CMSA or an approved provider, including E-learning and distance education. Should you have any doubts as to whether an activity qualifies for recognition by the CMSA as an approved PTD activity you should seek feedback and confirmation from the CMSA. PROFESSIONAL REFERENCES Referee Form 1 and Referee Form 2 Each candidate must submit two (2) professional references in support of their online application. These forms (i.e. Referee Form 1 and Referee Form 2) are available online at www.cmsa.org.au on the Membership Categories page of the website. Please download and save a copy to your personal computer. Please note all information must be typed into the form, saved and then printed prior to being signed and certified. You must then scan the certified copy and save a copy to your personal computer in readiness to attach to your online application. Hand written copies will not be accepted by the CMSA. To qualify as a professional referee the individual must: • Have been in a professional working relationship with you for at least six (6) months in the last three (3) years. • Be familiar with your professional practice and the content of your Fellow application. Examples of Professional Training and Development (PTD) activities. All PTD activities must be congruent to the candidate’s vocation and role (practical or theoretical) pursuant to case management.

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It is your responsibility to: • Ensure each referee understands their contribution to your application. • Share the content of your application and supporting documentation with your referees. • Provide a copy of the Fellow Application Guidelines to each of your referees.

• Download and provide a copy of Referee Form 1 and Referee Form 2 in Microsoft Office Word to each nominated referee. • Provide each referee with the CMSA contact details should they have any questions related to completing the Referee Form. • Check the completed form for any errors or omissions prior to having it certified. COMPLIANCE WITH THE NATIONAL STANDARDS AND NATIONAL CODE OF ETHICS FOR CASE MANAGEMENT As a Fellow you are required to commit to read, understand, utilise and apply the CMSA National Standards of Practice for Case Management (3rd Revised Edition, 2013) and National Code of Ethics for Case Management (2nd Edition, 2013) within all of your day-to-day professional interactions with your colleagues, community, clients and/or representatives, key stakeholders and employer. Your continued compliance to the same will afford you with the foundational platform in meeting the nationally recognised minimum practice standard of case managers within Australia and New Zealand and provide endorsement as to the veracity, integrity and fidelity of the profession of case management. INVESTITURE CEREMONY (OPTIONAL) An annual Investiture Ceremony will be held by the CMSA at each National Conference of the CMSA or, in the event the conference is bi-annual it will be held at a national location and date, as determined by the CMSA. A Fellow’s participation will be optional with all costs associated with this event to be incurred by the member, including formal graduation attire, admission tickets to the ceremony and related costs pertaining to the member’s attendance at this event. The CMSA will liaise with the Fellow as to the hire of the formal attire (e.g. robe and sash) and will facilitate the delivery and collection of the said attire to/from the venue. The CMSA will engage the services of professional photographer to attend this event and accordingly each member will receive a complimentary photo (included within the admission fee). The option for additional photos (“for a fee”) of Fellows with their colleagues, family or friends will also be available at the event with orders and payment made direct to the photographer. Please note, Fellows who have registered for this event and have not honoured payment of the nominated fees, pursuant to any required deadlines, will not be eligible to participate in the Investiture Ceremony. FEES Payment of fees Fees are required to be paid in full at the time of the online application. • Payment can be made by credit card, cheque or direct deposit. • All payments must be in Australian Dollars. • All fees are inclusive of GST. • An application will be considered pending until the payment has been honoured. • Discounts apply to CMSA members (i.e. Individual and Corporate 1-7). • Membership must be current for discounts to apply. • Discounts to CMSA Corporate Members 1-7 are capped at the total number of members per level of Corporate membership. • The application fee is inclusive of the total fee. • The application fee is non-refundable should a candidate’s application fail to be approved by the CMSA.

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Schedule of Fees

Fellow *non member* Application fee: $160.00 Registration fee: $290.00 Total fee: $450.00 Fellow *CMSA member* Application fee: $90.00 Registration fee: $290.00 Total fee: $380.00

Fellow *CMSA Corporate member* Application fee: $90.00 Registration fee: $290.00 Total fee: $380.00 APPEALS REGARDING AN APPLICATION CMSA Appeals Policy

All candidates applying for recognition as a Fellow are subject to the following:

1.1. Any candidates applying for Fellow membership who considers that they have been adversely affected by a decision of the CMSA in relation to the said application may, within fourteen (14) days of receipt of notice of such decision from the CMSA, apply to the Chief Executive Officer to have such decision reviewed by the CMSA Board. 1.2. Such application shall be in writing and accompanied by all relevant information or grounds upon which the candidate seeks to rely in relation to the review.

1.3. An appeal may only be made on one or more of the following grounds: (a) an error in law; (b) an error in the process; or (c) material not available or considered when the original decision was made.

1.4. The CMSA Board, upon considering all submissions, may: (a) confirm the decision under review; (b) revoke the decision under review.

1.5. The final decision of the CMSA Board is: (a) absolute and not subject to justification, further enquiry nor review. PRIVACY OF YOUR INFORMATION

The CMSA is covered by the National Privacy Principles, established under the Privacy Act 1988 (Act) as well as our existing obligations of confidentiality. The CMSA takes the privacy of individuals applying for membership seriously and seeks to comply with all elements of the National Privacy Principles (NPP) in its conduct. As part of the application process you are required to read and consent to the CMSA Privacy Policy at www.cmsa.org.au When you apply for membership you consent to the CMSA collecting, maintaining, using and disclosing personal information about you and provided by you or by another person in accordance with our privacy policy on the CMSA website www.cmsa.org.au The CMSA Privacy Policy explains how the Society collects, maintains, uses and discloses your personal information. It also provides some detail regarding your privacy rights along with the CMSA’s general rights, obligations and policy in relation to the personal information maintained on record.

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ATTACHMENTS The following attachments have been included for your reference only and includes copies of the forms you may be required to download from the CMSA website (Membership Categories page) and submit to the CMSA within your online application.

1. Employment Verification Form 2. Professional Training and Development (PTD) Form A 3. Professional Training and Development (PTD) Form B

4. Referee Form 1 5. Referee Form 2 6. Pathways to Certification

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Attachment 1 - Employment Verification Form, Page 1 of 2

FELLOW - EMPLOYMENT VERIFICATION FORM

The information being sought in this form is for the purpose of verifying the employment details of the named “Employee” (past or present) by your Organisation or Company. The “Employee” is seeking national recognition as a Fellow of the Case Management Society of Australia and New Zealand (CMSA). Pursuant to this application the “Employee” must submit evidence of their FTE vocational practice experience to the CMSA in accordance with the minimum pre-requisite requirements for the said application. It is important to know in completing this form for the “Employee”, and on behalf of your Organisation or Company, you may be contacted by a representative of the CMSA to either clarify or verify any details as provided within this form. Please complete, print and sign this form prior to returning it to the “Employee” . Information must be typed into this form. Handwritten versions of the form will not be accepted by the CMSA. I am providing employment information with the full knowledge and consent and as requested, for and on behalf of Title (Dr, Prof, Mr, Mrs, Ms): SURNAME: GIVEN/FIRST name:

TO THE EMPLOYER

“ Employee ” details

“Employee” address: “Employee” position title within your Organisation or Company: If more than one please list. Practice area of “ Employee ” (as it relates to case management): (e.g. academic, advisor, case manager, consultant, clinician, educator, executive, manager, mentor, policy planner, practitioner, supervisor, researcher etc) “Employer” Organisation or

Company Name: Postal address: Suburb: State/Territory (Australia):

Town/City (New Zealand): Postcode: Country: Name of person completing form on behalf of the “Employer” Organisation or Company as named above:

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

GIVEN/FIRST name:

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Attachment 1 - Employment Verification Form, Page 2 of 2

“Employer” Job Title: “Employer” Business Phone:

“Employer” Mobile: “Employer” Email:

Date of “Employee” appointment: Is the “Employee” presently employed with your Organisation or Company?

Yes No Please provide end date of employment contract:

Average hours of “Employee” per week ?

hours

“Employee” FTE equivalent of hours for term of employment? FTE are based on 38 hours per week over 48 weeks. Do you know of any information that may give rise to concern of the “Employee” that may disqualify the “Employee” as being a fit and proper person for recognition by the CMSA as a Fellow? Total “Employer” Comments (optional): Please add any additional information or comments in relation to the “Employee” that you consider relevant for the attention of the CMSA. “Employer” Declaration:

Yes Please provide details: No

I solemnly and sincerely declare that the information I have provided is true and correct to the best of my knowledge and belief. I solemnly and sincerely declare that I have not omitted any information that may give rise to concerns by the Case Management Society of Australia and New Zealand (CMSA) as to the appropriateness of the “employee” receiving recognition as a Fellow nor unduly challenge the veracity, integrity or fidelity of the Society, its members and the profession of Case Management.

“Employer” Signature:

_________________________________________

Date:

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

FELLOW- PROFESSIONAL TRAINING & DEVELOPMENT FORM PART A

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 Fellow Application Guidelines. As part of the CMSA ’s ongoing Quality Assurance it is important that you understand that the Society will conduct random audits of Fellow 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.

TO THE APPLICANT

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

Applicant details:

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:

Description of PTD activity: Please state relevancy of activity to your practice area/role as it relates to Case Management.

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

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 CMSA Fellow 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:

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

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 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):

Applicant details:

SURNAME:

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

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

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:

Signature:

_________________________________________

Date:

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

Attachment 4 - Referre Form 1 - Page 1 of 2

FELLOW - REFEREE ONE (1) FORM

Your role as a “ referee ” is important in the substantiation of information provided by the “ applic ant” to the CMSA. Applicants seeking recognition as a Fellow of the Case Management Society of Australia and New Zealand (CMSA) must provide full details of their referees. It is recommended by the CMSA that as a nominated referee you take the time to review and discuss the application and supporting documentation prior to it being submitted online to the CMSA. It is important to know that as a referee, you may be contacted by a representative of the CMSA to either clarify or verify any details or claims made by the applicant or yourself in support of the aforesaid application. Please complete, print and sign this form prior to returning it to the applicant. Information must be typed into this form. Handwritten versions of the referee form will not be accepted by the CMSA.

TO THE REFEREE

Applicant Name:

I am providing a professional reference for (insert full name):

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

Referee 1 details

SURNAME:

GIVEN/FIRST name:

Position title: Organisation or Company name: Postal address: Suburb: State/Territory (Australia):

Town/City (New Zealand): Postcode: Country:

Phone: Mobile: Email: In what professional capacity do you know the applicant? (e.g. academic, advisor, case manager, colleague, consultant, clinician, educator, executive, manager, mentor, peer, policy planner, practitioner, supervisor, researcher etc)

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