You need DA Form 5441-12, and this page gets you to the file and through it. Start with what the form is: EVALUATION OF CLINICAL PRIVILEGES - DIAGNOSTIC RADIOLOGY, used to evaluation of clinical privileges - diagnostic radiology. Check next that you have the right version — the edition dated 02/01/2004 is the one published here, and its status is ACTIVE. Then look at the size before you begin, because 1 page(s) and roughly unknown fields tell you how long this will take. Before you go further, note that a newer edition exists. Use this one only if you are looking at a record already completed on it.
Next, find out whether you are the one who fills it. In most cases you complete the entries yourself, and an administrator in your unit reviews what you wrote before it moves on. If you are the administrator, you will be working from what the individual gives you. Either way, TSG owns the form and AR 40-68 tells you when to raise it and where it goes afterward, so read the directive first if your situation is not routine.
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.
Once you reach the body of the form, move between fields with the tab key rather than the mouse; it follows the order the form was built in and you are less likely to skip a box. Click check boxes and option buttons directly. When you meet a group of options where only one can apply, notice that selecting a second one clears the first — that is intended, not a fault. Watch your longer answers as you type them. A single-line field does not wrap, so text that runs past the edge stays visible on screen and then prints cut off. When you see that happening, stop and move the text to the remarks area or a continuation instead of squeezing it in. If a field does not apply to you, mark it rather than leaving it empty; a blank space tells the reviewer nothing about whether you considered the question or missed it.
Save the signature for last. Sign by hand, or by whatever electronic method your office accepts, and understand that until you do the document is a draft no matter how complete it looks. If the form calls for a reviewing official, an approving authority, or a witness, take those signatures in the order the blocks print, and have each signer date it on the day they sign rather than the day you prepared it. Before you hand it over, read it once more from the top. You are looking for three things in particular: a mandatory field you left empty, digits transposed in your identification number, and a date written with day and month the wrong way round. Check one more thing if you built this form from a copy you had lying around — old entries survive in a reused file, and they will go forward as though you meant them.
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
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.
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.
Now send it on. Follow the routing in the prescribing directive, which will point you to a named office, to your unit administrative channel, or to your own file. Take a copy before you release it. From there the record follows the retention schedule for the series, and neither you nor the receiving clerk shortens or extends that on local judgement.
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 5441-12?
- EVALUATION OF CLINICAL PRIVILEGES - DIAGNOSTIC RADIOLOGY
- 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