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Attachment 9 - Re-endorsed Certified Case Manager™ - Professional Training & Development Form - Page 1 of 2

RE-ENDORSED CERTIFIED CASE MANAGER™ - PROFESSIONAL TRAINING & DEVELOPMENT FORM

The information being sought in this form is for the purpose of verifying your 24 hours of Professional Training and Development (PTD) undertaken in the last 3 years and backdated from the date of your previous endorsement (i.e. registration date) as a Certified Case Manager™ by the CMSA. Activities undertaken must be related to Case Management and specific to your practice area/role as it relates to case management (practical, managerial or theoretical). Instructions for completing this form along with full details of approved PTD activities are available online at www.cmsa.org.au Please go to [Navigation tab] Certification [Drop down menu] Applying To Be Certified / Professional Training & Development Activities Explained. As part of the CMSA’s ongoing Quality Assurance of Certified Case Manage rs™ it is important that you understand that the Society will conduct random audits of Certified Case Manager™ re -endorsement 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. 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 (Prof, Dr, Mr, Mrs, Ms.):

SURNAME:

GIVEN/FIRST name:

PTD Activity details: Please number each activity (ie. 1, 2 etc) and label your responses to questions (a) – (f) below (e.g. 1a, 1b, 1c, 1d, 1e & 1f and 2a, 2b, 2c, 2d, 2e and 2f etc)

(a) Title of PTD activity: (b) Date of PTD activity: (c) Presenter/company:

(d) Description of PTD activity: (e) Supporting evidence of the PTD activity: (f)Total time (hr/min) of activity:

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.