You need DA Form 5441-19, and this page gets you to the file and through it. Start with what the form is: EVALUATION OF CLINICAL PRIVILEGES - DIETETICS, used to evaluation of clinical privileges - dietetics. 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 2 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.
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.
Begin with the first block and follow the printed order. You will enter your name first, exactly as your official records show it, followed by your identification number, your organisation, and the date of preparation. Resist the urge to jump to the substantive blocks and return to the header later. Those first entries are the index for the whole record, and an error there costs you the ability to retrieve it.
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.
Sign at the end and not before. Use ink or the electronic method your office accepts; whatever the state of the entries, an unsigned form is still a draft. When a reviewer, approver or witness has to sign as well, collect those signatures in printed block order and make sure each one is dated the day it was applied, not the day you started. Then read the form through once from the beginning. Three faults account for most rejections: a required field left blank, an identification number with two digits swapped, and a date whose day and month are reversed. Add a fourth if you began from an old working copy — data left over from the last time will travel forward untouched.
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
Now pick your file. You have PDF, XFDL to choose from, and the choice depends on one thing: whether you will type the entries or write them by hand. Choose the fillable pdf when you want to type, tab between fields and keep a clean copy on your computer. Choose the printable pdf when you intend to print the blank first and write on paper. The pages look identical either way, so you are not giving anything up by picking the wrong one — you are only choosing how you work.
Then take care with how you open what you downloaded. Your browser will happily display a pdf, and for reading that is enough — but for typing it is not, because some in-browser viewers accept keystrokes and then throw them away when the tab closes. Put the file somewhere on disk, open it in a proper reader, type into one field and save, and confirm the text is still there when you reopen. If you picked up the xfdl copy, get the IBM Lotus Forms Viewer before you go any further, because nothing else will open the file.
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.
If you find you need a second form to go with this one, look by series and number. Forms in the DA series that share a proponent or a prescribing directive are often used together, and any form named on the face of this one normally goes forward with it. Gather continuation sheets, cover sheets and transmittal documents before you submit, not after somebody asks for them.
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.
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 5441-19?
- EVALUATION OF CLINICAL PRIVILEGES - DIETETICS
- 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)