Clinical Placement Unit
(PRE-ALLOCATION) SPECIAL CONSIDERATION REQUEST
* 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 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 your Special 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
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Form lodgement options
In Person
Campus Central
City East Campus
Playford Building, level 3
(*Mark 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:
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 SPS Amended:
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/ OR
 Placement due:
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 No Variation
 Student Notified:
CPUOffice@unisa.edu.au
Fax: 08 8302 2830
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/
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:

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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: ______________________________________
Clinical Placement Unit Use Only:
 Received:
/
/
 SPS Amended:
/
/ OR
 Placement due:
/
/
 No Variation
 Student Notified:
Date:
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/
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