DA Form 5440-15: Certified Nurse Midwife Privileges Guide

DA Form 5440-15: Certified Nurse Midwife Privileges Guide – Certified Nurse Midwives (CNMs) play a vital role in U.S. military healthcare, providing comprehensive women’s health services with a focus on pregnancy, childbirth, postpartum care, and gynecologic needs. In the U.S. Army, DA Form 5440-15 standardizes the process for granting, reviewing, and documenting clinical privileges for these providers.

This article explains the form’s purpose, key sections, completion process, and importance for Army Medical Department (AMEDD) professionals. It serves as a resource for CNMs, supervisors, credentialing staff, and medical facility commanders.

What Is DA Form 5440-15?

DA Form 5440-15, titled Delineation of Clinical Privileges – Certified Nurse Midwife, is an official U.S. Army form (February 2004 edition) used under AR 40-68 (Clinical Quality Management). It defines the scope of practice for CNMs in Army medical treatment facilities (MTFs).

The form ensures privileges align with the provider’s education, certification, experience, and demonstrated competence while matching facility capabilities and mission needs. It follows Department of Defense and Army credentialing standards for safe, high-quality care.

Download the official form here: DA Form 5440-15 PDF.

Purpose and Regulatory Background

The form supports the privileging process, which grants permission for specific clinical activities. CNMs manage low-risk pregnancies, labor, deliveries, and women’s health care, often collaborating with physicians for higher-risk cases.

Key governing references:

  • AR 40-68 (Clinical Quality Management).
  • DoD policies on medical quality assurance and privileging.
  • American College of Nurse-Midwives (ACNM) standards for education and certification.

Privileges require current licensure, national certification (e.g., by the American Midwifery Certification Board), and proof of competence.

Who Uses DA Form 5440-15?

  • Certified Nurse Midwives (Army Nurse Corps 66W or civilian equivalents) applying for or renewing privileges.
  • Supervisors/Department Chiefs who review and recommend approvals.
  • Credentials Committees/Functions at Army MTFs for final recommendations.
  • Commanders as the approving authority.

It applies to active duty, reserve, National Guard, and civilian CNMs in Army facilities.

Key Sections of DA Form 5440-15

The two-page form includes provider details and coded privilege requests.

Provider Information

  • Name, rank/grade, facility.

Coding System (Provider and Supervisor)

  • 1 — Fully competent.
  • 2 — Modification requested (with justification).
  • 3 — Supervision requested.
  • 4 — Not requested (lack of expertise).
  • 5 — Not requested (lack of facility support/mission).

Supervisors use similar codes for approval recommendations.

Section I: Procedures (Core Privileges)

Primary Care & General:

  • Patient screening, immunizations, profiles (including pregnancy), diagnosis/treatment of acute/chronic illnesses.

Adolescent and Adult Women:

  • Gynecologic care, uncomplicated obstetric/postpartum management.
  • History & physical exams, prescribing medications (per P&T committee), ordering labs/imaging.
  • Admissions to Labor Ward, labor/delivery management (low-risk), postpartum care, contraceptive counseling, well-woman exams (including peri-/post-menopausal).

Ambulatory Procedures:

  • Pap smears, microscopic exams, electronic fetal monitoring, limited OB ultrasound, IUD insertion/removal, etc.

Inpatient Procedures:

  • Labor augmentation, internal monitoring, amniotomy, episiotomy/repair, normal spontaneous vaginal delivery, manual placenta removal, laceration repairs, newborn resuscitation, first assist for C-section, lactation support.

Providers strike through or initial inapplicable items. Additional comments go in designated areas.

Sections II & III: Recommendations

  • Supervisor’s overall recommendation.
  • Credentials Committee/Function recommendation.
  • Signatures and dates.

How to Complete and Submit DA Form 5440-15?

  1. Provider completes Section I, codes requested privileges, and signs.
  2. Supervisor reviews, codes approvals, and provides recommendation.
  3. Credentials Committee reviews and recommends.
  4. Commander grants final approval.

Renewals require evidence of ongoing competence (e.g., case logs, quality reviews). Initial applicants need proof of education, certification, and recent clinical experience (such as deliveries).

Revisions to privileges require a new form. Maintain records per Army credentialing policies.

Why Proper Use of This Form Matters?

  • Patient Safety — Ensures CNMs practice within their verified competence.
  • Compliance — Meets Joint Commission, DoD, and Army standards.
  • Career Impact — Accurate privileging supports deployment readiness, promotions, and transitions to civilian practice.
  • Access to Care — Supports full-scope midwifery in military settings, improving outcomes for service members and families.

CNMs in the Army often enjoy strong support for autonomous practice within guidelines, with collaboration for complex cases.

  • Army Publishing Directorate: Search for DA Forms.
  • ACNM Guidelines on Credentialing and Privileging.
  • DoD Medical Quality Assurance policies.
  • Local MTF Credentials Office for facility-specific requirements.

For the most current version and guidance, always refer to official Army sources or your facility’s credentials manager. DA Form 5440-15 remains a foundational tool for integrating highly skilled Certified Nurse Midwives into Army healthcare teams.