DA Form 5441-5: OB/GYN Clinical Privileges Evaluation – DA Form 5441-5: Evaluation of Clinical Privileges – Obstetrics and Gynecology is a key U.S. Army document used in the credentialing and privileging process for healthcare providers specializing in OB/GYN care.
This form ensures that military physicians and qualified providers demonstrate the necessary competence for safe, high-quality patient care in obstetrics and gynecology within Army medical treatment facilities (MTFs). It supports the Army’s Clinical Quality Management Program under AR 40-68.
What Is DA Form 5441-5?
DA Form 5441-5 (dated February 2004) is titled “Evaluation of Clinical Privileges – Obstetrics and Gynecology.” It is prescribed by Army Regulation 40-68 for use by the Office of The Surgeon General (OTSG).
Department/service chiefs use it to evaluate providers’ demonstrated patient management abilities and technical skills. It pairs with DA Form 5440 series forms for initial delineation of privileges.
Key purposes:
- Assess competence across categorized procedures and skills.
- Document ratings: Acceptable, Unacceptable, or Not Applicable.
- Support reappraisal, renewal of privileges, and medical staff appointments.
- Ensure alignment with facility capabilities and patient safety standards.
Download the official form here: DA Form 5441-5 PDF.
Structure and Content of the Form
The form includes provider details (name, rank/grade, evaluation period, department, facility) and detailed evaluation sections.
Section I – Department/Service Chief Evaluation lists privileges in four categories:
Category I (Core/basic privileges):
- Normal antepartum and postpartum care
- Normal labor and delivery
- Maternal-fetal monitoring
- Episiotomy and repair of second-degree laceration
- Local infiltration and pudendal block anesthesia
- Cervical biopsy, cryosurgery, LEEP, colposcopy
- Others like sigmoidoscopy.
Category II (Intermediate):
- Dilation and curettage
- Salpingo-oophorectomy, tubal interruption
- Amniocentesis
- Repair of third/fourth-degree lacerations
- Neonatal resuscitation, low forceps, manual placenta removal.
Category III (Advanced):
- Hysteroscopy, laparoscopy
- Hysterectomies (abdominal, vaginal, laparoscopic-assisted)
- Cesarean deliveries
- Urodynamic exams, obstetric/gynecologic ultrasound, moderate sedation.
Category IV (Highly specialized/complex):
- Radical gynecologic surgeries
- Lymphadenectomy
- Microsurgery
- In-vitro fertilization procedures
- Advanced reconstructions and special procedures (e.g., laser application, flaps).
Evaluators mark a privilege approval code (from the corresponding DA Form 5440) and rate performance. Any “Unacceptable” rating requires explanation in Section II – Comments.
How DA Form 5441-5 Fits Into Army Credentialing?
Under AR 40-68, the Army’s Clinical Quality Management Program (CQMP) governs privileging to maintain high standards in military healthcare.
Providers request privileges via DA Form 5440. Supervisors and department chiefs evaluate performance using DA Form 5441-5 during initial granting, renewal, or focused professional practice evaluations (FPPE). Privileges are facility-specific and based on training, experience, current competence, and volume of procedures.
This process aligns with broader Department of Defense and civilian standards (e.g., Joint Commission requirements for competency). Recent MHS reforms streamline privilege transfers across facilities while maintaining rigorous evaluation.
Who Uses This Form?
- Army OB/GYN physicians (active duty, civilians, contractors) in military hospitals and clinics.
- Department chiefs and credentials committees.
- Providers transitioning roles or seeking reappointment.
It ensures providers meet requirements similar to civilian hospital privileging, such as board certification by the American Board of Obstetrics and Gynecology (ABOG) and documented procedural experience.
Why It Matters for Patient Safety and Readiness?
Accurate privileging protects Service members, families, and beneficiaries by matching provider skills to assigned duties. In OB/GYN, this covers routine prenatal care to complex gynecologic oncology procedures, supporting military family health and deployment readiness.
For USA-based military healthcare professionals or those researching Army medical processes, understanding these forms is essential for compliance and career progression.
Tips for Completing and Using DA Form 5441-5
- Review all applicable procedures and line through non-relevant ones.
- Base evaluations on direct observation, case logs, and outcomes.
- Provide detailed comments for any concerns.
- Retain records as part of the provider’s credentials file.
- Consult the latest AR 40-68 for policy updates.
Note: Forms and regulations can be updated. Always verify the most current versions on official Army Publishing Directorate sites (armypubs.army.mil).