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Use DA Form 5440-53 when you need to delineation of clinical privileges - occupational medicine. Full title: DELINEATION OF CLINICAL PRIVILEGES - OCCUPATIONAL MEDICINE. Everything you need is on this page — the file, the entry rules, the routing. Edition 02/01/2004, status ACTIVE, 3 page(s), roughly unknown fields. Note the supersession: a later edition exists, and this one applies only to records already completed on it.
TSG is the proponent, AR 40-68 the prescribing authority. Read the directive only if something about your situation departs from the standard case. Otherwise the form is filled by the individual it describes, or by the records clerk keeping the file, and reviewed through the printed signature blocks.
Pick by how you will enter data: PDF, XFDL on offer. Typing means fillable pdf, where the boxes accept keystrokes and hold them on save. Handwriting means printable pdf, a flat page image sent straight to a printer. Neither version changes what appears on the page.
Use a full pdf reader, not the browser viewer. Browser viewers display fields they cannot always save, and the loss shows up only when you reopen the file — type one entry, save, reopen, verify, then fill the rest. The xfdl file is IBM Lotus Forms, used inside Army systems, and opens in the Lotus Forms Viewer alone — no pdf reader, no word processor.
Nothing is charged and no sign-up applies. Files are served as published, without changes to the page image.
Header first, always. Name as your official records spell it, identification number, unit, date of preparation — these four index the finished record, and an error in them hides the document from anyone searching for it later. The substantive blocks can wait thirty seconds.
Tab through the fields rather than clicking. The tab order was fixed when the form was built and generally follows the page, which catches boxes a mouse skips past. Check boxes and option buttons take a click, and an exclusive group clears the previous selection when you make a new one. Single-line fields do not wrap — text past the field width prints truncated while still showing in full on screen, which is why the loss is discovered after printing. Overflow goes to remarks or a continuation sheet. A field that does not apply gets the mark meaning none; blank space reads as an omission.
Sign last. An unsigned form is a draft whatever else is on it, and additional signatures — reviewer, approver, witness — follow printed block order with each signer dating the day they sign, not the day of preparation. Four faults account for most returns: a blank mandatory field, transposed digits in an identification number, day and month reversed in a date, and leftover entries in a working copy reused instead of a fresh blank. Read the form once from the top before releasing it.
Privacy Act statement first, personal entries second. The notice covers who is authorised to collect, why, who else routinely sees it, and whether you must answer. After completion the file carries personal data and is stored and sent under the corresponding safeguards.
Routing follows AR 40-68 and nothing else — a named office, the unit administrative channel, or the individual's file, according to why the form was raised. Copy it before it leaves. Retention is fixed by the records schedule for the series, which local practice does not shorten or extend.
Companion documents come from the same series and number scheme. Within the DA series, a shared proponent or a shared directive usually means shared use, and a form cited on the face of another accompanies it. Gather the whole package first — continuation sheets, cover sheets, transmittals.
A stored file goes stale silently. The proponent revises, a new edition date is published, and your copy says nothing about it — so compare the printed date against the edition in force before typing into it again. Completed submissions on an earlier edition are not reopened.
What is distributed here are reproductions of published Department of the Army documents. Independent site, no official standing, no forms of its own. Nothing on the page constitutes legal advice, and acceptance by any office is outside what can be stated. Put questions about entries, requirements or eligibility to TSG or your servicing administrative office.
Questions and answers
- What is DA Form 5440-53?
- DELINEATION OF CLINICAL PRIVILEGES - OCCUPATIONAL MEDICINE
- Which edition is current?
- 02/01/2004
- Who is responsible for this form?
- TSG
- In which formats can it be downloaded?
- PDF, XFDL, PDF
Publisher notes
- 42-ITEM ONLY PRODUCED IN ELECTRONIC MEDIA
- 14-REQUIRES PRIVACY ACT STATEMENT (AR 340-21)