Every entry on DA Form 5441-12 exists because a record system needs it in writing. The form's official title is EVALUATION OF CLINICAL PRIVILEGES - DIAGNOSTIC RADIOLOGY, and it is raised whenever an office must evaluation of clinical privileges - diagnostic radiology in a way that survives the departure of everyone involved. Memory does not transfer between assignments; a filed document does. The edition dated 02/01/2004, status ACTIVE, is what stands here, spread across 1 page(s) and about unknown fields — a count that reflects how much detail the receiving system requires, not how much the drafter wishes to give. A later edition has since been published, which is why this one remains: records executed against it must still be readable in the terms they were written.
The form has an author and an occasion, held by different authorities. TSG owns the content and reshapes it when what is being recorded changes. AR 40-68 governs the event that calls for the form and the route the finished document takes afterwards. Keeping those two apart is what allows a procedure to be amended without the page being rebuilt each time.
Identification precedes substance for a structural reason. Name, identification number, organisation and date of preparation are how the finished document is located in a file or a database; the body of the form is what someone reads after the search has succeeded. Spell the name as official records spell it, since the search runs against those records and not against habit.
Tab order is not a convenience feature; it was fixed when the form was built and generally traces the page, so following it produces the sequence the designer intended and leaves fewer gaps than a mouse. Exclusive option groups clear the previous selection because the record is not permitted to hold two contradictory answers. Single-line fields do not wrap for the same reason the layout is fixed: the printed page has to fall in known positions, so text past the field width is cut at the margin even though the screen still shows it whole. Overflow belongs in remarks or on a continuation, where there is room designed for it. And an inapplicable field is marked rather than skipped, since a blank tells a later reader nothing about whether the question was considered.
The signature is the point at which entries become an assertion someone stands behind, so it follows everything else and its absence leaves a draft. Countersignatures by reviewing, approving or witnessing officials each carry their own weight and are dated at signing, which is how the file preserves the order of responsibility. Seen that way, the familiar errors are not clerical trivia: an unanswered mandatory field, digits transposed in an identification number, day and month reversed, and residue from a reused file each put something false or unresolved into a document that will be relied upon.
Personal information may not be gathered silently, and the Privacy Act statement is how that obligation is met on paper: it names the collection authority, the purpose, the routine uses and whether disclosure is mandatory. Because it exists to inform a decision, it belongs before the fields it covers rather than after them. A filled copy then holds personal data and is stored and transmitted under the corresponding safeguards.
Download the form
The published formats — PDF, XFDL — reflect the range of places a form gets filled in. Where there is a computer, the fillable pdf supplies live fields that keep entries positioned and readable. Where there is not, the printable pdf gives the identical page as flat artwork for pen entry. The distinction is one of setting rather than of authority; the page is the same document in both.
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.
No charge and no account apply: these are published documents, and access to them is not something a distributor is entitled to price.
The routing in AR 40-68 decides where the document goes — a named office, the administrative channel, or the individual's file — and the records schedule for the series decides how long it stays. Neither is a local judgement, because a record system loses its meaning if each office keeps things for its own preferred interval. Copy the form before submitting it.
Related documents are located by series and number, and the relation is rarely accidental — forms under one proponent or one directive tend to serve steps of a single procedure. Anything the DA series form names on its face normally travels with it, as do the continuations, covers and transmittals the process generates. Assembling them together is what makes the submission a complete account.
Editions change because the process changes, and the printed edition date is the only marker of which version a page belongs to. A copy saved locally cannot know it has been superseded, so the date on it is compared against the edition in force before reuse. Records already executed under an earlier edition are left alone — a document is read under the terms it was made, and reopening completed files to match a later form would falsify the account.
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 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