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.