©ANZ Certification Application Guidelines eBook

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Attachment 4 - Referre Form 1 - Page 1 of 2

CERTIFIED CASE MANAGER™ - REFEREE ONE (1) FORM

Your role as a “referee” is important in the substantiation of information provided by the “applicant” to the CMSA. Applicants seeking national recognition as a Certified Case Manager™, i.e. Certified Practising Case Manager™ or Certified Case Manager (Non Practising)™, 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 for a Certified Case Manager™. 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):

Referee 1 details

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

SURNAME:

GIVEN/FIRST name:

Position title:

Organisation or Company name:

Postal address:

State/ Territory

Postcode

Country if other than Australia

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) How long have you known the applicant? Please record approximate time in years and actual time in months if this period is less than 2 years.

The Case Management Society of Australia (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.