Begin by matching the form to your task. DA Form 5440-53 is titled DELINEATION OF CLINICAL PRIVILEGES - OCCUPATIONAL MEDICINE, and you reach for it when you need to delineation of clinical privileges - occupational medicine. Once that matches, check the date. The edition here is 02/01/2004, published with the status ACTIVE. After that, glance at the length: you will be working through 3 page(s) and somewhere near unknown fields. Check this before anything else — a more recent edition is out. Stay on this one only if the record you are handling was already completed on it.
Then work out your role. If the entries describe you, you fill them in and someone in the administrative section checks the result. If you handle records for others, you enter what they supply and pass the form along. In both cases the same two references govern you: TSG maintains the form, and AR 40-68 sets out the trigger for using it and the route it takes. Read that directive before you start when anything about your case is unusual.
Start at the top of the page and work down. The heading blocks come first: write your name as it appears on your official records, then your identification number, then your unit or organisation, then the date you are preparing the form. Do not skip ahead to the interesting parts and come back — these heading entries are how your form is found in the file afterwards, and a form filed under a misspelled name is a form nobody can locate.
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.
You will find a Privacy Act statement on the form wherever personal information is collected. Read it at that point rather than skipping past it, because it tells you the authority for the collection, the purpose, the routine uses, and whether answering is mandatory. After you fill the form, remember that your copy contains personal data. Store it and transmit it as your office requires for records of that kind.
Download the form
Next comes the download itself. The formats available are PDF, XFDL, and you decide between them by asking how you will enter the information. If you plan to type, take the fillable pdf: the boxes accept keyboard input and you can save the result. If you plan to write by hand, take the printable pdf and run it through your printer while it is still blank. Both show the same published page, so the decision affects your method and nothing else.
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.
Finally, note what the download costs you: nothing. You do not create an account, you do not enter an email address, and the file you receive is the published document with nothing added to it.
With the form signed, send it where AR 40-68 tells you to send it — usually to the office it names, or through your unit administrative channel, or straight into your own record, depending on why you raised it. Keep a copy for yourself before it leaves your hands. How long the receiving office holds it is not your decision or theirs; the records schedule for the series settles that, and local habit does not override it.
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.
Check the edition date again the next time you reach for this form. Editions change when the proponent revises the content, and a copy you saved months ago may no longer be current — compare the date printed on your file against the edition in force before you type anything into it. What you do not need to do is redo work already finished: a form you completed and submitted under an earlier edition stays as it is.
One last thing to be clear about before you download. What you get here is a copy of a published Department of the Army document. This site is not part of the Department of the Army, issues no forms of its own, and cannot tell you that any office will accept what you submit. Nothing written on this page is legal advice. When you are unsure about a particular entry, a requirement or whether you are eligible at all, ask TSG or the administrative office that services your unit — they answer those questions and we do not.
Questions and answers
- What is DA Form 5440-53?
- DELINEATION OF CLINICAL PRIVILEGES - OCCUPATIONAL MEDICINE
- 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)