First, confirm you are on the right form. DA Form 5440-28 carries the official title DELINEATION OF CLINICAL PRIVILEGES - SOCIAL WORK, and you use it to delineation of clinical privileges - social work. Second, check the edition: the copy offered here is dated 02/01/2004 and its publication status is ACTIVE. Third, size up the job — 2 page(s) and about unknown entry fields, so you can decide whether to fill it now or set aside time. One thing to settle first: a later edition has been issued. Reach for this one only when you are working with a record already executed on it.
Now decide who does the writing. Normally you enter your own particulars, then hand the sheet to the unit administrative office for review. If you work in that office, you enter what the individual brings you. From there the path is the same for everyone: TSG is responsible for the form, and AR 40-68 tells you what triggers it and where it ends up. Look at the directive first whenever your case departs from the ordinary.
Work from the top down, one block at a time. First the name — copy it from your official records rather than writing it the way you usually do. Then the identification number, then the unit, then today's date. Fill these before anything else. When the form reaches a file cabinet or a database, these are the entries someone searches on, so get them right before you worry about the rest.
Now for the body. Use tab to advance through the fields; the order was set when the form was built and following it keeps you from leaving gaps. Check boxes and option buttons take a click. Where the options are mutually exclusive, choosing one will clear another, which is how the group is meant to behave. As you type longer entries, watch the field edge. One-line fields do not wrap, and anything past the edge prints missing even when you can still read it on screen — when that happens, put the text in remarks or on a continuation sheet. Leave nothing blank because it does not apply; enter the mark that means it does not apply, so the reviewer knows you read the question.
Leave the signature until everything else is done. Sign by hand or by an approved electronic means, and remember that a form without a signature is a draft, however complete the entries. Where a second and third signature are required — reviewing official, approving authority, witness — go in the order the blocks appear, and each signer dates the form on the day of signing. Then go back to the top and read what you wrote. Look first for a mandatory field you passed over, then for transposed digits in your identification number, then for a date with the day and month inverted. If you started from a file you had used before, look also for entries left from that earlier use; nothing removes them but you.
At some point while filling the form you will meet a Privacy Act statement, and you should read it when you reach it rather than after you finish. It tells you who is authorised to collect the information, what it will be used for, who else may see it, and whether you are obliged to answer or may decline. Once you have entered your details, treat the file accordingly: it now holds personal information about you, so store it and send it the way your office handles such records.
Download the form
Then choose a file to download. What you will see offered is PDF, XFDL, and the only question you need to answer is whether you are typing or writing. Type, and you want the fillable pdf, where the entry areas respond to your keyboard. Write, and you want the printable pdf, which you print empty and complete with a pen. The layout does not change between them, so pick whichever fits how you plan to work today.
Once the file is on your machine, open it deliberately. A pdf will usually launch in your browser, which reads well enough but does not always hold what you type; certain viewers display the fields and then discard your entries. Save the download to a folder, open it from there in a dedicated reader, and test one field and one save before you commit to filling the whole thing. If the xfdl file is what you need, install the IBM Lotus Forms Viewer first. No pdf reader and no word processor will open it.
Then simply download. There is no charge, no sign-up and no email to hand over, and the file that arrives is exactly what the publisher released.
Once you have signed, route the form. The prescribing directive names the destination: an office, your unit administrative channel, or your personal file, according to the case. Make yourself a copy first, because you will not get the original back. After that, retention is out of your hands — the applicable records schedule fixes how long the document is kept, whatever the practice in a particular office.
When another document has to travel with this one, find it by series and number. Forms in the DA series sharing a proponent or a governing directive are commonly used in combination, and anything cited on the face of your form generally goes with it. Assemble continuation sheets, covers and transmittals before you send the package rather than in response to a query.
The next time you open this form from your own files, check the edition date first. Revisions come from the proponent without warning to you, so the only reliable step is to hold your copy against the current edition before filling it in again. Records you already completed under a superseded edition stand, and you do not go back to rework them.
Read this before you go. The file you download is a reproduction of a published Department of the Army document, offered as it was published. We are an independent site with no connection to the Department of the Army and no authority to issue anything, and we make no statement about whether your completed form will be accepted anywhere. Treat what you read here as information, not legal advice. Take real questions — about an entry, a requirement, or your eligibility — to TSG or to your 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