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CHCCCS040 Support Independence and Wellbeing Assessment Outcome Report Form © 2023 Coast Wide Training Solutions | CHCCCS040 Assessment Outcome Report FORM V1.0-23 1 CHCCCS040 Support Independence and Wellbeing (Release 1) ASSESSMENT OUTCOME REPORT Student Name: Qualification/Program: Student Declaration By signing below, I declare that my assessor and or/other training staff have: ☐ Provided me with access to policies including the assessment policy/assessment appealsprocess,☐Explained the unit of competency, elements, and performance criteria that I studied inthe course,☐Explained the assessment tasks, assessment criteria and the assessment due date(s) forthis course; and☐ Provided assistance during the study of this course (unit/s) when I requested help.By signing below, I declare that I: ☐ Hold a copy of this assignment in case the original is lost or damaged,☐ Am submitting work for this assessment task that is my own and no other person hascompleted this assessment for me; and☐ Have not copied any part of this assignment or product from any other learner’s work orfrom any other source, except where I have referenced any sources I used.I am submitting the following evidence to support my claim for competence. Yes No N/A Assessment 1 – Theory Questions ☐ ☐ ☐Assessment 2 – Case Study ☐ ☐ ☐Assessment 3 – Practical Skills Demonstration ☐ ☐ ☐Workplace Verification Form ☐ ☐ ☐I have been provided with feedback on the evidence I have submitted. I have been informed of the assessment result and the reasons for the decision. Student Signature: Date: SAMPLE