THEORY ASSESSMENT COVER SHEET HLT40312 - Certificate IV in Massage Therapy Practice HLT50307 – Diploma of Remedial Massage STUDENT DETAILS STUDENT NAME / STUDENT CONTACT NUMBER AND EMAIL SUBMISSION DETAILS MODULE NAME ASSESSMENT TYPE (please tick) Contact Number Email _________________________________________________________________________  Theory Exam 1st Sitting  Re-Sit – Partial exam  Re-Sit – Whole exam  Assignment (name): _______________ 1st Submission  Re-submission NAME OF TEACHER TERM DUE DATE / EXAM DATE STUDENT DECLARATION  Term 1  Term 2  Term 3  Term 4 YEAR _____/_____ /_____ I confirm that this is my own work. I understand that there are penalties if this assessment is submitted after the stated due date, unless I have otherwise received approval for an extension to the due date. I accept that if my assessment is kept on campus it will only be kept for 12 months and in this time I can request to view my marked assessment. After the 12 month period it will be destroyed. Signature of Student: _____________________________________________ Date of Submission: _____/____ /____ TEACHER / ADMINISTRATION USE ONLY ASSESSMENT OUTCOME NAME OF ASSESSOR OUTCOME  Competent: I confirm that I observed the learner demonstrate the skills with the elements, performance criteria, critical aspects for assessment and required skills for this assessment task.  Not Yet Competent COMMENTS RESULT RECORDED ON ROLL _____/_____ /_____ STUDENT INFORMED:  Yes Assessor Signature: __________________________________________________ ADMINISTRATION  RESULTS RECORDED ON DATABASE _____/_____ /_____  No Date: _____/_____ /_____ STUDENT INFORMED:  _____/_____ /_____ COMMENTS Administration Signature: ______________________________________________ NSW School of Massage is a trading name of Australian Learning Group P/L RTO Provider No 91165 CRICOS 03071E (NSW) Date: _____/_____ /_____ AUSTRALIAN LEARNING GROUP Level 1, 225 Clarence Street Sydney 2000 p: +612 9112 4500 w: ALG.edu.au