DA Form 5441-11: Clinical Psychology Privileges Evaluation

DA Form 5441-11: Clinical Psychology Privileges Evaluation – DA Form 5441-11: Evaluation of Clinical Privileges – Clinical Psychology is a key U.S. Army document used to assess and document the competencies of clinical psychologists working in military healthcare facilities.

This form supports the Army’s Clinical Quality Management Program under AR 40-68, ensuring providers meet standards for safe, effective patient care.

What Is DA Form 5441-11?

DA Form 5441-11 (February 2004 edition) is titled “Evaluation of Clinical Privileges – Clinical Psychology.” It is used by Department/Service Chiefs to evaluate a psychologist’s performance across specific privilege categories.

The form pairs with DA Form 5440-11 (Delineation of Clinical Privileges – Clinical Psychology), which outlines requested privileges by category (I through IV) based on education, licensure, and experience.

Key details:

Why This Form Matters in the U.S. Army?

Clinical psychologists (often MOS 73B) deliver critical mental health services to Soldiers, families, and other beneficiaries in military treatment facilities (MTFs). Privileging ensures providers practice only within their verified expertise, supporting readiness, deployment health, and compliance with federal standards (e.g., 10 U.S.C. § 1094 on licensure).

Evaluations occur during initial appointment, reappraisal, renewal, or when performance issues arise. Ratings of “Unacceptable” require detailed explanations and may impact reappointment or lead to adverse actions.

Structure and Key Sections of DA Form 5441-11

The two-page form includes:

Header Information:

  • Provider name, rank/grade, evaluation period, department/service, and facility.

Section I – Department/Service Chief Evaluation: Evaluators rate privileges as Acceptable, Unacceptable, or Not Applicable, and enter approval codes (linked to DA Form 5440-11 categories).

Core Privilege Categories include:

  • Psychological Assessment and Diagnosis: Child, Adult, Forensic, Neuropsychological, Substance Abuse.
  • Outpatient Therapy Services: Individual, Group, Marital, Family, Child/Adolescent, Geriatric, Crisis Intervention, Sexual Dysfunction, Substance Abuse, Sexual Offender (with notes).
  • Health Psychology Services: Clinical hypnosis, biofeedback, psychological interventions in medical settings.
  • Inpatient Psychological Services: Admission, treatment/consultation, discharge, management of mental disorders, alcohol/drug residential treatment.
  • Consultation: Command, command-directed evaluations, community organizations, medical/surgical, school.
  • Other Specified Services: Disaster relief, personnel assessment/selection, SERE psychology (additional DoD credentialing required), aeromedical psychology, combat stress control, behavioral research.

Section II – Comments: Required for any “Unacceptable” ratings or additional context.

Evaluator Signature and Date.

How the Privileging Process Works? (AR 40-68)

  1. Provider completes DA Form 5440-11 to request privileges based on qualifications (e.g., APA-accredited doctorate, internship, state licensure, experience).
  2. Supervisor/Department Chief uses DA Form 5441-11 to evaluate performance.
  3. Credentials Committee reviews and recommends.
  4. Privileging authority (e.g., MTF Commander) approves, modifies, or denies.
  5. Periodic re-evaluations ensure ongoing competence.

Categories generally progress from supervised (Category I) to fully independent/board-certified (Category IV).

Who Uses This Form?

  • Active Duty Army Clinical Psychologists.
  • Army Reserve and National Guard behavioral health providers.
  • Civilian psychologists employed or contracted by Army MTFs.
  • Supervisors and credentials officials in medical commands.

Similar processes exist in other services (e.g., Air Force MPL for Clinical Psychology).

Tips for Completing and Using DA Form 5441-11

  • Base evaluations strictly on observed performance and documentation.
  • Line through and initial non-applicable items.
  • Provide specific, objective comments—especially for limitations.
  • Retain in the provider’s credentials file per AR 40-68.
  • For SERE or specialized roles, ensure additional credentialing.

Note: Forms are subject to official Army updates. Always use the latest version from armypubs.army.mil.

  • AR 40-68: Clinical Quality Management (governs the full process).
  • DA Form 5440-11: Delineation companion form.
  • Army Clinical Psychologist (73B) career information.

For military psychologists and healthcare administrators, mastering DA Form 5441-11 is essential for maintaining high standards in behavioral health care and supporting Soldier mental readiness. Consult your local credentials office or Medical Command for facility-specific guidance.