DA Form 5441-28: Social Work Clinical Privileges Guide

DA Form 5441-28: Social Work Clinical Privileges Guide – Clinical privileging ensures that social workers in U.S. Army medical treatment facilities (MTFs) deliver safe, high-quality behavioral health care to Service members, families, and other beneficiaries. DA Form 5441-28, titled Evaluation of Clinical Privileges – Social Work, serves as the key document for this process.

What Is DA Form 5441-28?

DA Form 5441-28 is a standardized U.S. Army form used to evaluate the clinical competencies of social work providers. Department/Service Chiefs complete it as part of the periodic reappraisal and renewal of clinical privileges.

Key Details:

  • Date of Form: February 2004 (DA FORM 5441-28, FEB 2004)
  • Proponent: Office of The Surgeon General (OTSG)
  • For Use With: AR 40-68, Clinical Quality Management
  • Official Download: Army Publishing Directorate

This form pairs with DA Form 5440-28 (Delineation of Clinical Privileges – Social Work), which defines requested privilege categories.

Purpose and Importance in Army Credentialing

The Army requires privileging for all healthcare providers, including clinical social workers (73A), to verify demonstrated patient management abilities and technical skills. Evaluations occur during initial appointment, renewal (typically every two years), and focused reviews.

Core Objectives:

  • Assess competence in psychosocial assessments, diagnoses, treatments, and case management.
  • Ensure compliance with DoD and Army standards for behavioral health services.
  • Support quality patient care in inpatient, outpatient, and specialized programs (e.g., Family Advocacy, Substance Abuse).

Unacceptable ratings require detailed explanations in Section II – Comments, which directly influence reappointment decisions.

Structure of DA Form 5441-28

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. They enter the privilege approval code from the corresponding DA Form 5440.

Main Privilege Categories for Social Work:

Category I Clinical Privileges (typically for those with MSW but not yet fully licensed): Basic services under supervision.

Category II: Licensed social workers providing independent assessment, diagnosis, and treatment.

Category III: Advanced licensed clinical social workers with specialized skills and extensive experience (e.g., 12+ years).

Specific Privileges Evaluated Include:

  • Psychosocial assessments (individual, group, marital, family, child/spouse/elder abuse, sexual abuse, etc.)
  • DSM diagnosis
  • Command-directed behavioral health evaluations
  • Inpatient/outpatient social work treatment (individual, group, family, child/adolescent therapy, substance abuse, sexual offender treatment)
  • Case management (Family Advocacy, discharge planning, etc.)
  • Other specialized areas (e.g., foster care, adoption, home health referrals)

Section II – Comments: Required for any unacceptable ratings or additional observations.

Signatures and Dates: Evaluator, provider acknowledgment (as needed), and final approvals.

Who Uses This Form?

  • Providers: Army clinical social workers (active duty, civilian, contractors) seeking or renewing privileges.
  • Evaluators: Department/Service Chiefs or designated supervisors.
  • Credentials Committee: Reviews for final approval of privileges.
  • Facilities: All Army MTFs and behavioral health programs.

Military social workers often hold an MSW from a CSWE-accredited program and state licensure (LCSW or equivalent). They support Soldier readiness through counseling, crisis intervention, and family services.

Step-by-Step Process for Completing and Using the Form

  1. Preparation — Review the provider’s credentials file, performance records, and DA Form 5440-28 delineation.
  2. Evaluation — Rate each applicable privilege based on direct observation, chart reviews, and peer input.
  3. Documentation — Explain any deficiencies thoroughly.
  4. Review & Approval — Route through the credentials function per AR 40-68 Chapter 9.
  5. Retention — File in the provider’s credentials folder for ongoing quality management.

Note: Procedures must align with current AR 40-68 (2004 with 2009 RAR) and DoD policies on licensure and privileging.

  • DA Form 5440-28: Delineation of Clinical Privileges – Social Work (defines categories I-III).
  • AR 40-68: Governs the full clinical quality management and privileging process.
  • Army Publishing Directorate (armypubs.army.mil) for all DA forms.
  • Local MTF Credentials Office for facility-specific guidance.

Why Proper Use of DA Form 5441-28 Matters?

Accurate evaluations maintain high standards in Army behavioral health, protect patients, support provider professional development, and ensure compliance with federal requirements (e.g., 10 USC Chapter 55). For social workers, successful privileging enables full-scope practice in high-demand areas like trauma, substance abuse, and family advocacy.

Download the Form Here: Official DA Form 5441-28 PDF

For questions on completion or privileging, consult your facility’s Credentials Manager or refer directly to AR 40-68. Always use the latest official versions from Army sources to ensure compliance.