Clinical Placement Unit

(Pre-Allocation) SPECIAL CONSIDERATION REQUEST

* 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 Special Consideration Request will be considered only prior to initial placement allocation and only in the circumstances listed on the back of this form,with those circumstances substantiated by documentation.

This form is to be lodged no later than 12 weeks prior to the date of placement commencement. Forms received closer to placement than 12 weeks will be considered but a late request will jeopardise capacity for allocation of a suitable placement.

Please briefly outline the reason for yourSpecial Consideration request and attach supporting documentation – note that in the case of Disability Access Plans a letter or email from the Learning and Teaching Unit will suffice. Requests 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 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

  • Special Consideration requests are available only prior to the initial allocation of placements, not after allocation has been conducted.
  • A Request for Variation to Placement form is used post initial allocation of placement.
  • The Special Consideration request will be considered 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 such as those outlined in clause 7 of the Assessment Policies and Procedures Manual.
  • Supporting documentation must accompany this form. Where the request 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.

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: / /