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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

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.

TO THE APPLICANT

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:

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

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

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

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.