PDF
Word
DA Form 5440-11 Delineation of Clinical Privileges-Psychology
What Is DA Form 5440-11?
This is a military form that was released by the U.S. Department of the Army (DA) on February 1, 2004. The form, often mistakenly referred to as the DD Form 5440-11, is a military form used by and within the U.S. Army. As of today, no separate instructions for the form are provided by the DA.
FAQ
Q: What is DA Form 5440-11?
A: DA Form 5440-11 is a form used for delineating clinical privileges for psychology.
Q: What is the purpose of DA Form 5440-11?
A: The purpose of DA Form 5440-11 is to document and authorize clinical privileges for psychologists.
Q: Who uses DA Form 5440-11?
A: DA Form 5440-11 is used by psychologists and those responsible for granting clinical privileges.
Q: What does the form require?
A: The form requires information about the psychologist's education, training, experience, and references.
Q: How is clinical privilege determined?
A: Clinical privilege is determined based on the psychologist's qualifications and ability to provide competent and safe care.
Q: Can clinical privileges be revoked?
A: Yes, clinical privileges can be revoked or modified if there are concerns about the psychologist's competency or conduct.
Q: Is DA Form 5440-11 specific to the US and Canada?
A: Yes, DA Form 5440-11 is specific to the US and Canada as it is related to their military and healthcare systems.
Form Details:
- A 2-page document available for download in PDF;
- The latest version available from the Army Publishing Directorate;
- Editable, free, and easy to use;
- Fill out the form in our online filing application.
Download an up-to-date printable DA Form 5440-11 down below in PDF format or browse hundreds of other DA Forms stored in our online database.
Download DA Form 5440-11 Delineation of Clinical Privileges-Psychology
1
2
