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DA Form 5441-21 is a DA series document issued for use across the Department of the Army. Official title: EVALUATION OF CLINICAL PRIVILEGES - PHYSICAL THERAPY. Purpose: evaluation of clinical privileges - physical therapy. The current edition carries the date 02/01/2004 and is listed with a publication status of ACTIVE. The form runs to 1 page(s) and contains approximately unknown entry fields.
Proponency for the form rests with TSG. The governing authority is AR 40-68, which establishes the circumstances of use and the required routing. Preparation falls to the individual named in the entries or to the unit administrator acting on that individual's behalf; review and signature follow the chain set out in the governing authority. A later edition of this form exists. The edition shown here is superseded and is retained for reference and for records already executed on it.
Formats offered: PDF, XFDL. All are the same published layout in different containers, and the choice between them is a matter of how the entries will be made rather than what appears on the page. The pdf serves as the authoritative rendering. A fillable pdf exposes editable fields on screen; a printable pdf is the blank form as a flat page for handwriting.
The pdf displays in current browsers and in any reader application. For fillable use a full reader is preferable to a browser viewer, since viewers vary in whether entered data is retained. An xfdl file is available too. The format is IBM Lotus Forms, in use across Army form systems, and it opens only in the Lotus Forms Viewer.
Every format is available at no charge and without sign-up. Files are distributed exactly as published, with no changes to the page.
The blocks are worked through in the order they appear on the sheet. At the head sit the identifying entries: name, identification number, unit, date. Because the filed record is indexed on these, they precede everything substantive.
Fillable fields accept typing directly. Tab advances from one field to the next in the order the form was built, which is normally the reading order of the page. Check boxes and option buttons are clicked; where a set of options is exclusive, selecting one clears the rest. Fields sized for a single line will not wrap, and text exceeding the width is truncated in print even where it remains visible on screen. Long entries belong in the remarks area or on a continuation, not compressed into a narrow field.
Signature comes at the end, applied in ink or by an accepted electronic method. Until it is applied the document is a draft. Additional signatures — reviewer, approver, witness — are taken in printed block order, each dated when signed rather than when the form was drafted. The commonest error is a mandatory field left blank; where nothing applies, the entry is marked accordingly instead of being skipped. Transposed identification digits, day and month reversed in dates, and carried-over data from a reused working copy account for most of the remainder.
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.
The completed form is routed as the governing authority prescribes: to the office named in the directive, through the unit administrative channel, or into the individual's file, depending on the case. A copy is retained by the preparer. Filing and retention follow the records schedule applicable to the series rather than local practice.
Associated documents are located through the series and number scheme. Forms in the DA series with the same proponent or the same prescribing directive tend to be used as a set, and any form named on the face of another normally accompanies it. Continuations, cover sheets, and transmittals fall into this category and are gathered before the package is sent.
Revision by the proponent supersedes an edition. Version is read from the edition date printed on the form itself, and a stored copy is compared against the current edition before it is used again. Documents already executed under an earlier edition are not redone because of the change.
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 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