Broken Hill Department of Rural Health

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 Friday 12 December 2008. 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 Monday 12 January 2009. This is the earliest date for commencement of student placements.

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

University Details
*Australian university and campus
Other or International university
*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

Do you already have IT access to Dubbo SRH server? (Usyd students only)
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 12 December 2008, recommences Monday 12 January 2009. Please contact Student Coordinator if you have specific enquiries about dates.