THEORY ASSESSMENT COVER SHEET

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