DA Form 5441-33: Urology Clinical Privileges Evaluation

DA Form 5441-33: Urology Clinical Privileges Evaluation – U.S. Army physicians, physician assistants, and other qualified healthcare providers in urology rely on standardized tools to maintain high-quality patient care and meet credentialing requirements. DA Form 5441-33, titled Evaluation of Clinical Privileges – Urology, serves as a critical document in this process.

This article explains the form’s purpose, structure, key procedures it covers, and how it fits into Army medical credentialing. It targets active-duty, reserve, and civilian providers supporting military healthcare facilities.

What Is DA Form 5441-33?

DA Form 5441-33 (February 2004 edition) is an official U.S. Department of the Army form used to evaluate a provider’s competence in performing urological procedures and managing patients. It supports the granting, renewal, or modification of clinical privileges in Army medical treatment facilities (MTFs).

The form is prescribed under AR 40-68 (Clinical Quality Management), with the Office of The Surgeon General (OTSG) as the proponent agency. It pairs with DA Form 5440 series documents that outline specific privilege approval codes.

Download the official PDF here: DA Form 5441-33

Purpose of the Form

The primary goal of DA Form 5441-33 is to ensure providers demonstrate:

  • Competence in patient management specific to urology.
  • Technical skills for listed procedures.
  • Safe, high-quality care aligned with military healthcare standards.

Evaluators (typically department/service chiefs) rate each procedure or category as Acceptable, Unacceptable, or Not Applicable. Any “Unacceptable” rating requires detailed explanation in Section II – Comments. These evaluations directly influence reappraisal, renewal of privileges, and medical staff appointments.

This process aligns with broader Department of Defense and Army credentialing standards, emphasizing ongoing professional practice evaluation (OPPE) and focused professional practice evaluation (FPPE).

Key Sections of DA Form 5441-33

Section I – Department/Service Chief Evaluation

Providers are evaluated across major urology categories:

  • Urological Cancer Surgery: Radical/partial nephrectomy, radical cystectomy, radical/simple prostatectomy, radical orchiectomy, exenterative procedures, ileal conduit, continent diversion, ultrasound-guided prostate biopsy.
  • Infertility Surgery (microscopic): Vasectomy, vasovasostomy, vasoepididymostomy, varicocelectomy.
  • Laparoscopic Surgery: Pelvic lymphadenectomy, varicocelectomy, nephrectomy, diagnostic laparoscopy.
  • Stone Surgery: Uretero-pyeloscopy, open lithotomy, extracorporeal shock wave lithotripsy (ESWL).
  • Endoscopic Surgery: Transurethral resection of the prostate (TURP), transurethral resection of bladder tumor (TURBT), endoscopic surgery of the urethra, cystoscopy, percutaneous endoscopic surgery.
  • Surgery for Impotence: Placement of penile prosthesis, penile orthoplasty.
  • Female Urology: Bladder neck suspension, bladder sling, major reconstruction.
  • Pediatric Urology: Hypospadias repair, orchiopexy, reconstructive procedures of genitalia/bladder/ureter/kidney, surgery for congenital anomalies.
  • Reconstructive Surgery: Placement of artificial urinary sphincter, male sling surgery, open urethroplasty, pyeloplasty.

A privilege approval code (from the corresponding DA Form 5440) is entered for each category. Procedures not performed can be lined through and initialed.

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

The form includes provider details (name, rank, period of evaluation, facility) and evaluator signature.

Who Uses This Form?

  • Urologists and urology-trained providers in Army hospitals and clinics.
  • Credentialing committees and department chiefs.
  • Medical staff services for initial appointment, reappointment, and privilege renewal.

Similar forms exist for other specialties (e.g., DA Form 5441 series), ensuring uniform evaluation across Army medicine.

Army providers typically align with civilian benchmarks, such as:

  • Board certification by the American Board of Urology (ABU).
  • Documented recent experience and continuing medical education (CME).
  • Successful completion of ACGME-accredited residency training.

Military-specific requirements may include deployment readiness and unique operational skills.

How to Complete and Submit DA Form 5441-33?

  1. Fill in provider information and evaluation period.
  2. Review each procedure/skill with the evaluator.
  3. Assign codes and ratings.
  4. Provide comments for any issues.
  5. Obtain signatures and route through the facility’s credentialing office.

Providers should maintain supporting documentation of case logs, outcomes, and training for reviews.

Why Proper Use Matters?

Accurate completion of DA Form 5441-33 protects patients, supports provider careers, and ensures compliance with AR 40-68 and Joint Commission standards. It directly impacts the ability to practice independently in Army facilities.

For the most current guidance, consult your local Medical Treatment Facility (MTF) credentials office or the U.S. Army Medical Department Office of Quality Management resources.

Official Download: DA Form 5441-33 PDF