Application for student placements form

Please use this form to apply online for placements managed through the Broken Hill University Department of Rural Health including sites at Broken Hill, Menindee, Wilcannia, Balranald, Wentworth, Dareton, Bourke, Brewarrina and Coomealla. The BHUDRH manage placements on behalf of the Far West Local Health District and have programs that reach Western NSW Local Health District.

This application can also be used for accommodation only requests.

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

Please contact the Student Program Team on 08 8080 1200 if you have any queries.


Student details
*First name:
Second name :
Preferred name :
Email:(Hotmail accounts not permitted)
* (Primary)
* (Reconfirm your primary email)

Contact number:
* (Primary)
(Contact phone 2)
(Contact phone 3)
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

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)

Emergency contact:

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

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
Womens health


Primary Health Care
Community health
Aboriginal health

General Practice
GP Clinic

Remote Health

Nursing students



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



Community Health
Aged care
Child and family
Chronic care
Aboriginal health
Rural mental health
Rural Community
Lightening Ridge
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)

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


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: NSW Health requires all students be compliant in line with NSW Health Legislation for Immunisation, Code of Conduct and National Police Check. Upon success of your application, if you are compliant already this will be confirmed and if you are not yet compliant, you will receive all information necessary to assist you in this process. For non-NSW Health placements, different requirements may apply and will be outlined accordingly in correspondence from the Student Program Team. Please refer to the following page for more information: [[nw[||Applications]]

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.*