Application for student placement form

Please use this form to apply online for the Student Placement Program at Broken Hill UDRH.

Please note applications are dealt with on an individual basis, and subject to availability of accommodation and placements.

Please contact the Student Coordinator if you have specific inquiries about dates.

 

Student details
*Surname:
*First name:
Second name :
Preferred name :
DOB:
(dd/mm/yyyy)
*Address:
*Town/Suburb:
State:
*Country:
Postcode:
Email:
* (University/TAFE email)
* (Reconfirm University/TAFE email)
* (Personal email)
Contact number:
* (Primary)
(Contact phone 2)
(Contact phone 3)
*How long have you ever lived in a rural area?
*Gender
Male Female
*Australian Nationality
Yes No
Aboriginal or Torres Strait Islander
Yes No
International exchange student
Yes No
International fee-paying
Yes No

 

Education Provider Details
*Australian university and campus
Other or International university
*University Student ID
*Discipline:

If other, please specify

Current year of study
Placement year of study:
Program path :

If other, please specify


Course coordinator(if known)
Name *
Phone *
Email *


Emergency contact:
*Name
*Phone
Email
Relationship

Placement details
*Preferred placement Start date (dd/mm/yyyy)
*Preferred placement End date (dd/mm/yyyy)
Have you completed a Cross Cultural AwarenessProgram?

Yes No

If YES,
Did you complete it at UDRH? Yes No
Date completed at UDRH (dd/mm/yyyy)





Preferred placement areas (Placement options will be advised following receipt of application)
Medical students
 

Acute Care - Broken Hill Hospital
Medical team
Broken Hill Extended Clinical Placement Program
Accident & emergency
Surgical team
Paediatrics
Psychiatry
Womens health

 

Primary Health Care
Aboriginal health
Community health
Mental health

General Practice
GP Clinic - Broken Hill

Remote Health
Bourke
Cobar
Wilcannia
Menindee

Nursing students

 

 

Acute Care - Broken Hill Hospital
Accident & emergency
Ambulatory Care Services
ICU
Maternity
Medical ward
Paediatrics
Operating Theatre
Surgical ward

 

 

Community Health
Aged care
Child and family
Chronic care
Aboriginal health
Rural mental health
Rural Community
Balranald
Cobar
Menindee
Bourke
Dareton/Wentworth
Walgett
Brewarrina
Lightening Ridge
Wilcannia
Allied Health
 

Hospital
School
Aged
I would like to have a mix of my selected options

Pharmacy
 

Community pharmacy
Hospital pharmacy

Social work
 

Hospital
Social community services

Other students
 

Acute In-patient
Community Out-patient
Other, please specify



Accommodation details
*Do you require accommodation?

Yes No

If yes, please specify dates (dd/mm/yyyy)
Start  End

   
   


Travel details
Mode of travel to placement
Date of arrival (dd/mm/yyyy)
Do you hold a valid Australian driver's license?


Comments
Please specify any special requirements such as wheel chair access, health issues or any other needs that may be relevant to your placement.


 

Students are required to forward a Photo ID to the following emails address:fwlhd-udrhstudentprogram@health.nsw.gov.au including name and date application submitted.

NSW Health Department requires students to have a current Criminal Record Clearance. If not already held, see your University Program Administrator for assistance.
Please note: Original Criminal Record Clearance is required to be sighted on the first day of placement.

Immunisation Status: New South Wales Health requires all students to present their Immunisation Records to the Risk Management Unit for processing before a placement can commence. Please read Immunisation requirements

Upon submission of this application form, an email confirming receipt will be directed back to you. Your application will be reviewed and you will be contacted either via email or phone regarding your application. If you do not receive any acknowledgement of your initial enquiry within 10-15 working days please contact the student placement coordinator on phone: +61 8 8080 1200.

I have read the conditions-information provided and agree to the conditions associated with my application.*