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DA Form 5440-28 is a Department of the Army form in the DA series. Title of record: DELINEATION OF CLINICAL PRIVILEGES - SOCIAL WORK. Function: delineation of clinical privileges - social work. The edition presently published bears the date 02/01/2004, with a status of ACTIVE. Physical extent is 2 page(s) and about unknown fillable fields.
The office of primary responsibility is TSG. Use is prescribed by AR 40-68, which defines when the form is raised and where it goes afterward. The form is normally completed by the subject of the entries or by administrative personnel maintaining the record, then reviewed and signed as the governing authority directs. A more recent edition has been published. This edition is superseded; it remains available for reference and for files already executed against it.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.
Every format is available at no charge and without sign-up. Files are distributed exactly as published, with no changes to the page.
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.
Typed entry is made straight into the interactive fields. The tab key moves through them in the order set at build time, generally matching the reading order of the page. Boxes and buttons respond to a click; in an exclusive group, one selection cancels the others. Single-line fields do not wrap, and anything longer than the field width prints cut off although it may still display in full on screen. Extended text goes to remarks or a continuation sheet rather than into a narrow box.
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.
Forms that collect personal information bear a Privacy Act statement covering authority, purpose, routine uses, and whether the disclosure is required or optional. Reading it precedes completion. Once filled, the document contains personal data and is subject to the handling and storage rules that attach to such records.
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.
Companion forms are traced by series and number. Within the DA series, documents sharing a proponent or a governing directive are frequently required together, and a form cited on the face of another is generally submitted alongside it. Continuation sheets, covers, and transmittal forms are part of that set and are assembled in advance of submission.
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.
The documents on this page are reproductions of published Department of the Army forms, offered for download. This is an independent site with no connection to the Department of the Army and no authority to issue forms. Nothing stated is legal advice, and no assurance is given regarding acceptance by any office. Doubts about a specific entry, requirement, or eligibility are resolved by the proponent or by the servicing administrative office.
Questions and answers
- What is DA Form 5440-28?
- DELINEATION OF CLINICAL PRIVILEGES - SOCIAL WORK
- 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