Clinical Placement Unit

(POST ALLOCATION) Request for Variation to Placement

* Mandatory fields on both sides of form

Student Name*______

Student ID*______Year* ______

Program*______

Course Name *______Course ID* ______

Before you complete and lodge this form, please read and sign the information on the back of the form. This form will not be accepted without all mandatory fields completed.

A Request for Variation to Placement will be considered only in the circumstances listed on the back of this form with those circumstances substantiated by documentation.

Unless otherwise advised by the CPU, this form is to be lodgedno later than 5 working days following initial notification to you of your placement allocation. Only in emergency circumstances will the request be considered after this timeframe.

Please briefly outline the reason for yourplacement variation request and attach supporting documentation. Applications without supporting documentation will not be considered.

*Student Signature______*Date / /

Form lodgement options

InPerson / By Post / By Scan/Email or Fax
Campus Central
City East Campus
Playford Building, level 3
Mark the envelope “confidential to the CPU”. Campus Central will date the envelope. / Clinical Placement Unit
Division of Health Sciences
University of South Australia
GPO Box 2471, Adelaide SA 5000 /
Fax: 08 8302 2830

IMPORTANT: Please read and sign the following before submitting your request

  • All students should be aware of the need for placements when they accept an offer into their program and are expected to organise personal, work and other commitments to enable placements as scheduled.
  • The CPU’s website contains information about financial support on placement, including UniSA Placement Grants.
  • Variation to a placementallocationwill normally only be consideredafter allocation of placements and only in the following circumstances:
  • Students with a disability access plan
  • Students who are the registered carer for a sick or disabled dependent child or relative, with the relevant documented evidence
  • Students with a major health problem requiring frequent and specialised treatment which is only available at certain locations, with the relevant documented evidence
  • Other highly extenuating medical, compassionate or special circumstances outside of the control of the student and where there is no opportunity to plan ahead, such as those outlined in clause 7 of the Assessment Policies and Procedures Manual.

**Note that in most of these situations, a Special Consideration Request formcan be submitted (no later than 12 weeks before placement is due) so that, if the request is accepted, the circumstances can be taken into account in the initial placement allocation.

  • Supporting documentation must accompany this form. Where the request for variation to placement involves a medical and/or disability situation the CPU will discuss the request with the Course Coordinator to ensure any special placement needs are met. In some cases, students with a medical certificate noting placement limitations, for example on travel to a placement or attendance at a specific site, may be asked to gain a more detailed medical opinion on their fitness for placement at that time.
  • In the current very competitive placement environment it is rare that an alternative placement will be available, except possibly a rural one. If the Request is accepted and an alternative placement is available it will be offered. If there is no alternative placement available, or the student does not accept the alternative offered, the only option is variation to the student’s Study Plan or prescribed program, which must be discussed with the Program Director. In the case of Nursing and Midwifery, all Study Plan variations, including mode of study, MUST be discussed with the Program Director.
  • Request for variation to placement will not be considered in the following circumstances:
  • Travel, transportation and accommodation requirements, except where issues are relevant to the circumstances listed above.
  • Student work or other business commitments.
  • Being a parent, except in the circumstances outlined above.
  • Weddings and other celebratory events.
  • Extra -curricular activities such as clubs.
  • Requests to be re-allocated to placement sites previously allocated but not attended or where the student withdrew from the placement.

I have read and understand this information:

*Student Signature: ______Date: / /

Clinical Placement Unit Use Only:

 Received: / /

 SPS Amended: / / OR  No Variation

 Placement due: / / ______Student Notified: / /