Clinical Placement Unit
(POST ALLOCATION) REQUEST FOR VARIATION TO PLACEMENT
* Mandatory fields on both sides of form
STUDENT NAME*
__________________________________________________________________________
STUDENT ID*
______________________________
PROGRAM*
___________________________________________________________________________
COURSE NAME *
__________________________________________ ________
YEAR* ___________________________________
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 lodged no 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 your placement variation request and attach supporting
documentation. Applications without supporting documentation will not be considered.
*Student Signature __________________________________________ *Date
/
/
Form lodgement options
In Person
Campus Central
City East Campus
Playford Building, level 3
Mark the envelope “confidential to
the CPU”. Campus Central will date
the envelope.
By Post
By Scan/Email or Fax
Clinical Placement Unit
Division of Health Sciences
University of South Australia
GPO Box 2471, Adelaide SA 5000
Clinical Placement Unit Use Only:
 Received:
/
/
 SPS Amended:
/
/ OR
 Placement due:
/
/
 No Variation
 Student Notified:
CPUOffice@unisa.edu.au
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 placement allocation will normally only be considered after 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 form can 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: ______________________________________
Clinical Placement Unit Use Only:
 Received:
/
/
 SPS Amended:
/
/ OR
 Placement due:
/
/
 No Variation
 Student Notified:
Date:
/
/
/
/