Download the form
DA Form 5441-22 handles one job: evaluation of clinical privileges. The official title is EVALUATION OF CLINICAL PRIVILEGES. Download it below, fill it in, sign it, send it where your directive says. The edition on this page is 02/01/2004, status ACTIVE, running 2 page(s) with about unknown fields to complete. This edition is superseded — pull the newer one unless your record was already executed on this version.
Authority sits in two places. TSG owns the form, AR 40-68 says when it is raised and where it goes. Routine cases need neither read in full — the page itself carries the sequence. The entries are completed by their subject or by unit administrative staff working from what that person supplies.
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.
No charge, no account, no email address. The file is the published document, distributed unaltered.
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.
Move between fields with tab; the build-time order follows the page and misses nothing. Click check boxes and option buttons, and expect an exclusive group to release the old choice when you set a new one. The trap is field width. Single-line fields do not wrap, so an overlong entry displays complete on screen and prints cut at the margin — put it in remarks or on a continuation instead. Mark inapplicable fields rather than leaving them blank, since an empty box carries no information about whether the question was read.
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.
The Privacy Act statement is read before the personal entries, not after. It gives the collection authority, the purpose, the routine uses and whether disclosure is mandatory or voluntary. Once filled, your copy is a personal record and gets stored and transmitted accordingly.
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.
Related forms are found by series and number. DA series documents under the same proponent or the same prescribing directive are commonly required as a set, and any form named on the face of this one goes forward with it. Assemble continuations, covers and transmittals before submitting, not after the query comes back.
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 5441-22?
- EVALUATION OF CLINICAL PRIVILEGES
- 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)