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


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: 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

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.*