Administrative documents are written for readers who were not present, and DA Form 5440-53 is no exception. Titled DELINEATION OF CLINICAL PRIVILEGES - OCCUPATIONAL MEDICINE, it is used to delineation of clinical privileges - occupational medicine — a transaction that means little in conversation and a great deal in a file. The published edition here carries the date 02/01/2004 and the status ACTIVE. Its 3 page(s) and roughly unknown fields are sized to what the record must prove years later, which is always more than the moment appears to need. A newer edition exists. This one is retained because the documents completed on it were completed under its terms and are read under them.
Behind any Army form sit two separate decisions. What the document asks is settled by TSG, which maintains and revises it. Whether you raise it, and where it goes once signed, is settled by AR 40-68. That division is the reason a form can outlive several changes in the process it serves.
Retrieval governs the order of entry. The head of the form takes name, identification number, unit and date, and those values become the handles by which the record is found later — the substantive blocks are never searched on. This is why the spelling must match official records exactly rather than approximately.
Much of the form's behaviour follows from its being a fixed page. Tab order was set at build time along the reading sequence, which is why tabbing catches boxes a pointer passes over. Exclusive groups release one choice when another is made because a record cannot carry two answers to a single question. Single-line fields refuse to wrap because every entry must print where the layout expects it — text beyond the width is lost at the margin, visible on screen to the end. That is what remarks areas and continuation sheets are for. Marking a field that does not apply matters for a related reason: emptiness is ambiguous, and a reviewer reading the file later cannot distinguish an omission from a decision.
A signature is what converts entries into a record, which is why it comes last and why an unsigned form remains a draft however complete it looks. Where a reviewing official, an approving authority or a witness also signs, each adds a distinct attestation, and each dates the day of signing rather than the day of preparation — the dates trace the sequence of responsibility. The recurring defects are worth knowing precisely because they defeat that purpose: an empty mandatory field leaves an obligation unmet, transposed identification digits attach the record to nobody, a date with day and month reversed puts events in the wrong order, and entries left in a reused working copy assert facts nobody intended.
The Privacy Act statement is on the page because collecting personal information requires the collector to disclose the terms first — the authority relied on, the purpose, the routine uses, and whether an answer is required or may be withheld. That order is the point: the statement is read before the entries it governs, since consent given afterwards is not consent. Once completed, the copy is a personal record and carries the handling obligations that attach to one.
Download the form
Why several files for one page? Because the form has to be completed in a headquarters and in places without a workstation, and PDF, XFDL covers both. The fillable pdf holds interactive fields that fix each entry in place and remove handwriting from the equation. The printable pdf is the same layout without those fields, meant for a printer and a pen. Neither is a lesser copy of the other; each answers a condition the other cannot.
Where a file opens matters more than it appears to. A browser will display a pdf, but browser viewers were built to read documents, and some accept keystrokes into fields they never intended to store — the entries are gone at tab close, without warning, because saving was never part of what that viewer does. A dedicated reader is built around the file's own structure and keeps what you enter. The xfdl file belongs to a different lineage entirely: IBM Lotus Forms, adopted across Army systems for the routing and signature handling built into it. That is why only the Lotus Forms Viewer reads it.
Downloads are free and unregistered. The material was published for general use, and the files are passed on unaltered.
Where the signed form goes is settled by AR 40-68 rather than by the office holding it — a named recipient, the unit administrative channel, or the individual's own file, depending on why it was raised. Retention likewise belongs to the records schedule for the series, which exists so documents are kept for as long as anyone might need them and no longer. Keep a copy before release; the original serves the file from then on, not you.
Forms cluster by series and number for the same reason files do: shared proponency and a shared prescribing directive usually mean a shared process. So a document in the DA series referenced on the face of another is generally part of the same transaction, and continuation sheets, cover sheets and transmittals belong to the package from the outset rather than arriving after a query.
An edition marks the form at a point in a process that keeps moving, and the date printed on the page is what distinguishes one from another. Since a saved file never announces its own obsolescence, compare its date against the current edition before using it again. Prior executions remain valid: the change applies forward, and a record is read against the edition it was written under.
A word on where this page sits. These are reproductions of published Department of the Army documents, made available by an independent site with no official role and no authority to issue forms. The structure described above — proponent, prescribing directive, records schedule — exists apart from this site entirely, which is why nothing written here is legal advice and why acceptance by any office is not something that can be promised. Put questions of entry, requirement or eligibility to TSG or to the administrative office servicing your unit.
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)