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Application for student placements 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 note that the student program will close on Wednesday 19th December 2012. All placements must be completed by this date.

The program will shut down for four weeks over the Christmas break. There will be no accommodation available for students during this time.

The student program will re-commence on Wednesday 2nd January 2013. This is the earliest date for commencement of student 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:
 * (Primary)
* (Reconfirm your primary email)
Contact number:
 * (Primary)
(Contact phone 2)
(Contact phone 3)
*Gender
 Male Female
*Australian Nationality
Yes No
Aboriginal or Torres Strait Islander
Yes No
International exchange student
Yes No
International fee-paying
Yes No

 

University 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


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


Mentor(if known)
Name
Phone
Email





Emergency contact:
*Name
*Phone
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)

If not at UDRH, please list the training organisation





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
Womens health

 

Primary Health Care
Community health
Aboriginal health

General Practice
GP Clinic

Remote Health
Wilcannia
Menindee
Nursing students

 

 

Acute Care - Broken Hill Hospital
Medical ward
Accident & emergency
Surgical ward
ICU

 

 

 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
Other students
 

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






Do you already have IT access to Dubbo SRH server? (Usyd students only)
Yes   No
   
   


Are you a recipient of rural / remote funding support / scholarship?
Yes   No
   
   


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)
   


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:udrhstudpr@gwahs.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: The New South Wales Department of 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.*
 
REMINDER:
Student program closes Friday 18th December 2009, recommences Monday 11th January 2010. Please contact Student Coordinator if you have specific enquiries about dates.