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DA Form 5440-11 is a DA series document issued for use across the Department of the Army. Official title: DELINEATION OF CLINICAL PRIVILEGES-PSYCHOLOGY. Purpose: delineation of clinical privileges-psychology. The current edition carries the date 02/01/2004 and is listed with a publication status of ACTIVE. The form runs to 2 page(s) and contains approximately unknown entry fields.
Responsibility for content and revision lies with TSG. The prescribing directive is AR 40-68, which sets both the trigger for use and the disposition of the completed document. Entry is made by the named party or by the records clerk holding the file, with review and signature applied in the prescribed order. This edition has been superseded by a newer one. It is kept accessible for reference and for records already completed under it.
Available formats: PDF, XFDL. Each is a rendering of the same official layout; the content is identical across them and only the means of completion differs. The pdf is the reference copy. Fillable pdf carries interactive form fields; a printable pdf is the same page image without them, intended for pen entry after printing.
A pdf opens in any current browser or in a dedicated reader. Fillable behaviour is more reliable in a full reader than in a browser viewer, where some field types render but do not save. An xfdl file is also published. This is the IBM Lotus Forms format used within Army systems; it requires the Lotus Forms Viewer and will not open in a pdf reader or a word processor.
All formats are free to download and no registration is involved. The files are the published documents, distributed unmodified.
Completion follows the printed sequence of blocks from the top of the page downward. The heading area takes the identifying particulars — name, identification number, organisation, date of preparation. Retrieval of the record from a file depends on these entries, and they are therefore filled first.
Interactive fields are filled by typing into them. Movement between fields is by tab, following the order established when the form was constructed, which usually tracks the page layout. Check boxes and radio groups are set by clicking, and exclusive groups permit one selection at a time. A one-line field has no wrap: text beyond its width prints truncated even when the screen shows it. Overlong content is placed in remarks or on a continuation, not forced into the field.
The signature block is completed last and by hand or by an accepted electronic means. An unsigned form is a draft. Where a second signature is called for — reviewing official, approving authority, witness — each is applied in the order the blocks appear and dated as of application, not as of preparation. Blank mandatory fields are the most frequent defect; a nil entry is marked as such rather than left empty. Other recurring faults: transposed digits in identification numbers, dates in the wrong order of day and month, and stale copies retaining prior data because a working file was reused instead of a fresh blank form.
Where personal information is gathered, the form carries a Privacy Act statement giving the collection authority, the purpose, the routine uses, and the mandatory or voluntary character of the disclosure. It is read before entries are made rather than afterwards. A completed copy holds personal data and is stored and transmitted under the corresponding safeguards.
Disposition of the completed document follows the prescribing authority — delivery to the office it names, transmission through the unit administrative channel, or placement in the individual's record, according to circumstance. The preparer keeps a copy. Retention is governed by the applicable records schedule, not by office custom.
Related forms are found by series and number. Documents in the DA series sharing a proponent or a prescribing directive commonly travel together, and a form referenced within the body of another is usually filed with it. Continuation sheets, cover sheets, and transmittal documents belong to this group and are collected before submission rather than after.
An edition stands until the proponent issues a revision. The printed edition date identifies the version, and a copy held locally is checked against the edition now in force before reuse. Prior executions under a superseded edition are not reopened for that reason.
What is offered here are copies of published Department of the Army documents, made available for download. The site is independent of the Department of the Army and publishes no forms of its own. The material is informational and not legal advice, and no statement is made about whether any office will accept a given document. Questions of entry, requirement, or eligibility go to the proponent or the servicing administrative office.
Questions and answers
- What is DA Form 5440-11?
- DELINEATION OF CLINICAL PRIVILEGES-PSYCHOLOGY
- 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,