Download the form
DA Form 5441-21 exists to evaluation of clinical privileges - physical therapy — that is the short version. Title of record: EVALUATION OF CLINICAL PRIVILEGES - PHYSICAL THERAPY. The page covers the download, the entries and the disposition, nothing else. Current here: edition 02/01/2004, status ACTIVE, 1 page(s), near unknown fields. Superseded edition. A newer one is out; stay here only for files already executed on this version.
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.
The heading entries carry more weight than the body. Name spelled as in official records, identification number, organisation, date prepared. Retrieval runs on those values, so a transposed digit or a casual spelling costs someone a file search. Fill them before anything else.
Tabbing beats clicking for coverage. The order was set at build time and tracks the page layout, so following it leaves no gaps. Boxes and buttons are clicked; where options are exclusive, one selection cancels another by design. Watch field width on long entries: one-line fields have no wrap, and what runs past the edge disappears in print though the screen still shows it. Move that text to remarks or a continuation. Never leave an inapplicable field empty — enter the nil mark, because a reviewer cannot distinguish a skipped question from a considered answer.
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.
Read the Privacy Act statement at the point it appears. Authority, purpose, routine uses, mandatory or voluntary — four facts, and they govern what you are about to enter. A completed copy holds personal data and takes the handling rules that attach to it.
The prescribing directive names the destination; office custom does not. Depending on the case that means a specific office, the unit administrative channel, or the personal record. Keep a copy first, because the original does not come back. Retention runs on the applicable records schedule.
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.
Check the edition date before reusing a saved copy. Revisions come from the proponent without notice to you, and the printed date is the only version marker on the page. Already-submitted records under a superseded edition stand as filed; the change does not run backwards.
These are reproductions of published Department of the Army documents, offered for download. The site is independent, connected to nothing official, and issues no forms of its own. Nothing here is legal advice and no statement is made about acceptance by any office. Questions about an entry, a requirement or eligibility go to TSG or your servicing administrative office.
Questions and answers
- What is DA Form 5441-21?
- EVALUATION OF CLINICAL PRIVILEGES - PHYSICAL THERAPY
- 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
- 14-REQUIRES PRIVACY ACT STATEMENT (AR 340-21)
- 42-ITEM ONLY PRODUCED IN ELECTRONIC MEDIA