Every entry on DA Form 5441-21 exists because a record system needs it in writing. The form's official title is EVALUATION OF CLINICAL PRIVILEGES - PHYSICAL THERAPY, and it is raised whenever an office must evaluation of clinical privileges - physical therapy 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.
Two offices stand behind the form, and the distinction between them explains most of what follows. TSG is the proponent: it decides what the form asks and revises it when the underlying process changes. AR 40-68 is the prescribing authority: it decides when the form is raised at all and where the completed document travels. Content and occasion are separated deliberately, so that a change in procedure does not require redesigning the page.
The heading blocks come first because the record is retrieved by them, not read into. Name as official records spell it, identification number, unit, date of preparation — those four are the index, and everything below them is content that only surfaces once the index has done its work. A form filed under a name written casually is not lost in principle, only in practice, which amounts to the same thing.
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.
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
Formats exist because completion happens under different conditions, not because anyone wanted variety. The published set is PDF, XFDL. A fillable pdf carries live entry objects, so typed text lands in fixed positions and stays legible whoever reads it later. A printable pdf drops those objects and leaves the page as an image, which is what an office needs where a screen is unavailable and a pen is not. The document itself is unchanged between them; what differs is the circumstance each anticipates.
The choice of application decides whether your work survives. Browsers render pdfs as documents to be read; where a viewer shows fields without a mechanism to store them, typed text disappears when the tab closes, and nothing announces the loss. A full reader treats the file as a form and preserves entries on save. The xfdl format comes from IBM Lotus Forms, used across Army systems because of the routing and signature functions built into it, and it opens in the Lotus Forms Viewer alone.
Downloads are free and unregistered. The material was published for general use, and the files are passed on unaltered.
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.
Series and number are how the DA series signals which documents belong together, and the grouping follows real process boundaries: a shared proponent or directive usually means a shared purpose. A form cited on the face of another is part of that same transaction, and continuation sheets, covers and transmittals complete it.
Revision follows the process, which is why editions appear without a fixed interval, and the printed date rather than any version number identifies them. Nothing on a stored copy signals that it has aged; the check is manual. Work already completed under a superseded edition stands as filed, because the record was made under those terms and is properly interpreted under them.
It is worth being plain about what this page is within all of the above. The files are reproductions of published Department of the Army documents, offered for download by a site with no official standing and no part in issuing anything. That matters because the machinery described here — proponency, prescribing directives, records schedules — runs entirely elsewhere. Nothing written here is legal advice, and no statement can be made about whether an office will accept a given document. TSG and the administrative office servicing your unit answer questions of entry, requirement and eligibility, and they are the ones positioned to.
Questions and answers
- What is DA Form 5441-21?
- EVALUATION OF CLINICAL PRIVILEGES - PHYSICAL THERAPY
- 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