DA Form 5441-15: CNM Clinical Privileges Evaluation Guide – Certified Nurse Midwives (CNMs) play a vital role in U.S. military healthcare, providing comprehensive care for women during pregnancy, childbirth, and beyond. In the Army, maintaining and evaluating clinical privileges ensures high standards of safety and competence. DA Form 5441-15, titled Evaluation of Clinical Privileges – Certified Nurse Midwife, is the official document used for this purpose.
This article provides a detailed overview for Army medical professionals, CNMs, credentials committees, and healthcare administrators in the United States.
What Is DA Form 5441-15?
DA Form 5441-15 is a U.S. Army form released in February 2004 for evaluating the clinical privileges of Certified Nurse Midwives. It is prescribed under AR 40-68 (Clinical Quality Management), with the Office of The Surgeon General (OTSG) as the proponent agency.
The form assesses a CNM’s demonstrated abilities in patient management, technical skills, and procedures specific to midwifery and women’s health. It supports reappraisal, renewal of privileges, and medical staff appointments or reappointments.
Official Download:
Download DA Form 5441-15 PDF
Purpose of the Form
The primary goal of DA Form 5441-15 is to ensure CNMs practice within their demonstrated competence while aligning with Army standards for quality patient care. Evaluations consider:
- Patient management in primary care, gynecology, obstetrics, and postpartum settings.
- Technical procedures ranging from routine screenings to labor and delivery interventions.
- Overall competence for granting, renewing, or limiting clinical privileges.
Any “Unacceptable” ratings require detailed explanations in Section II – Comments, which directly impact credentialing decisions.
Key Sections of DA Form 5441-15
The two-page form includes structured evaluations across several categories:
Section I: Department/Service Chief Evaluation
Evaluators rate privileges as Acceptable, Unacceptable, or Not Applicable. Categories include:
Primary Care
- Patient screening, immunizations, profile recommendations (including pregnancy), diagnosis/treatment of acute/chronic illnesses.
Adolescent and Adult Women
- Gynecologic care, uncomplicated obstetric/postpartum management, history & physical exams, prescribing approved medications, ordering labs/imaging, referrals, health maintenance, counseling, labor ward admissions, fetal monitoring, and well-woman care (including peri- and post-menopausal).
Ambulatory Procedures
- Incision & drainage, local anesthesia, biopsies, cryosurgery, cyst removal, clinical pelvimetry, Pap smears, microscopic exams, electronic fetal monitoring, limited ultrasounds, IUD/Norplant insertion/removal.
Inpatient Procedures
- Labor augmentation, internal monitoring, amniotomy, anesthesia blocks, episiotomy/repairs, normal spontaneous deliveries, manual placenta removal, laceration repairs, newborn resuscitation, lactation support, and first-assist for C-sections.
A privilege approval code (referencing the corresponding DA Form 5440) is entered for each item.
Section II: Comments
Required explanations for any unacceptable ratings. The evaluator (typically the Department/Service Chief) signs and dates the form.
Who Uses DA Form 5441-15?
- Certified Nurse Midwives in Army Medical Treatment Facilities (MTFs).
- Department Chiefs and supervising physicians conducting evaluations.
- Credentials Committees for privileging decisions.
- Army Nurse Corps and medical staff involved in quality management under AR 40-68.
Similar forms exist for other providers (e.g., DA Form 5441-16 for Nurse Practitioners), creating a standardized Army-wide system.
How to Complete DA Form 5441-15?
- Fill in provider details: Name, Rank/Grade, Evaluation Period, Department/Service, Facility.
- Evaluate each listed privilege/skill.
- Line through and initial non-applicable items.
- Enter approval codes and ratings.
- Provide comments for any issues.
- Obtain evaluator signature and date.
The form emphasizes demonstrated competence through patient records, outcomes, and ongoing professional practice evaluation. CNMs must typically show recent experience (e.g., deliveries) for initial or renewal privileges, consistent with broader military and civilian standards.
Importance in U.S. Army Healthcare
Clinical privileging protects patients and providers by matching scope of practice to verified skills. For CNMs, this supports safe, evidence-based care in maternity services, family planning, and women’s health across military installations. It aligns with Department of Defense policies and national standards from organizations like the American College of Nurse-Midwives (ACNM).
Accurate completion ensures compliance with AR 40-68, facilitates seamless recredentialing, and maintains readiness in military medicine.
Related Resources
- AR 40-68: Clinical Quality Management (governing regulation).
- DA Form 5440 series: Delineation of Clinical Privileges.
- DOD and Air Force equivalent privilege lists for CNMs.
- ACNM guidelines for hospital privileges and midwifery practice.
Pro Tip: Always use the latest version from official Army Publications (armypubs.army.mil) and consult your local credentials office or MTF policy for facility-specific requirements.
Stay Compliant and Prepared
Whether you are a Certified Nurse Midwife seeking privilege renewal, a supervisor conducting evaluations, or part of an Army credentials team, DA Form 5441-15 is essential for documenting competence in midwifery care.
Download the official form here: DA Form 5441-15 PDF
For questions on completing the form or Army privileging processes, contact your facility’s Credentials Office or refer directly to AR 40-68.