DA Form 5441-36: Audiology Clinical Privileges Evaluation – DA Form 5441-36 is the official U.S. Army form used for the Evaluation of Clinical Privileges – Audiology. It helps assess and document the competencies of audiologists working in Army medical facilities, ensuring they meet standards for patient care in hearing, balance, and related auditory services.
This form is a key part of the Army’s Clinical Quality Management Program under AR 40-68 (Clinical Quality Management), which governs privileging for healthcare providers in military treatment facilities (MTFs).
Why DA Form 5441-36 Matters for Army Audiologists?
Military audiologists play a critical role in diagnosing and treating hearing loss, balance disorders, and communication issues—especially for service members exposed to noise in training and combat. The form ensures providers demonstrate ongoing competence in core skills before receiving or renewing clinical privileges.
It pairs with DA Form 5440-36 (Delineation of Clinical Privileges – Audiology), where providers initially request specific privileges. The 5441-36 then evaluates performance during the review period.
Target users: Army audiologists (military, civilian GS, or contract), department chiefs, credentials committees, and medical staff at facilities like Brooke Army Medical Center or other MTFs.
Key Sections of DA Form 5441-36
The one-page form (FEB 2004 edition, still current) includes:
- Provider Information (Name, Rank/Grade, Evaluation Period, Department/Service, Facility)
- Instructions: Evaluations base on demonstrated patient management and technical competence. Use privilege codes from the corresponding DA Form 5440. Mark “Not Applicable” for codes 4 or 5. Explain any “Unacceptable” ratings.
Section I – Department/Service Chief Evaluation rates these core procedures/skills:
- a. Evaluation and diagnosis of hearing loss
- b. Retrocochlear function testing
- c. Cochlear function testing
- d. Evaluation and diagnosis of balance disorders
- e. Otoscopy and cerumen removal
- f. Treatment of hearing loss (hearing aids and ALDs – Assistive Listening Devices)
- g. Assessment and monitoring of communication ability
- h. Hearing conservation
- i. Evaluation, assessment, and monitoring of cochlear implants
- j. Approved patient research in audiology and hearing science
Ratings: Acceptable / Unacceptable / Not Applicable (with codes).
- Section II – Comments: Required for any unacceptable ratings; space for additional notes on performance.
- Evaluator Signature: Name, title, signature, and date.
Pro Tip: Line through and initial any non-applicable procedures.
How to Complete and Use DA Form 5441-36?
- Preparation — Review the provider’s performance over the evaluation period (FROM-TO dates).
- Evaluation — Department/Service Chief rates each skill based on direct observation, chart reviews, peer input, and outcomes.
- Documentation — Provide specific comments for any deficiencies.
- Submission — Forward to the credentials committee for privileging decisions (initial appointment, renewal, or modification).
- Retention — Part of the provider’s credentialing file per AR 40-68.
This process supports continuous quality improvement and patient safety in Army healthcare.
Download Official DA Form 5441-36 PDF
Direct official download (Army Publishing Directorate):
https://armypubs.army.mil/pub/eforms/DR_a/pdf/A5441_36.pdf
Always use the latest version from armypubs.army.mil for official use.
Related Forms and Resources
- DA Form 5440-36 — Delineation of Clinical Privileges – Audiology (request phase).
- AR 40-68 — Clinical Quality Management (full regulation governing privileging).
- Other DA 5441 series forms exist for different specialties (e.g., Optometry, Occupational Medicine).
For DoD-wide guidance, refer to DHA (Defense Health Agency) Medical Privilege Lists for Audiology, which align closely with Army processes.
Frequently Asked Questions (FAQ)
Who uses DA Form 5441-36?
Primarily Army audiologists and their supervisors in military treatment facilities for privileging and re-privileging.
Is the form still current in 2026?
Yes — the FEB 2004 edition remains the prescribed form under AR 40-68.
What happens if a privilege is rated “Unacceptable”?
It must be explained in Section II and considered during reappraisal or renewal. This may lead to modified privileges, additional training, or supervision requirements.
Can civilian or contract audiologists use it?
Yes, if they provide care in Army facilities and fall under the privileging process.
Need Help with Army Audiology Privileging?
For questions on completing DA Form 5441-36, contact your local Medical Staff Services / Credentials Office or refer directly to AR 40-68. Proper use of this form helps maintain high standards of audiology care for our service members and their families.