DA Form 5441-6: Optometry Clinical Privileges Evaluation

DA Form 5441-6: Optometry Clinical Privileges Evaluation – DA Form 5441-6 is the official U.S. Army form used to evaluate and document the clinical competencies of optometrists seeking or renewing clinical privileges in military treatment facilities (MTFs). It ensures that Army optometrists demonstrate the necessary skills to provide safe, high-quality eye care to service members, families, and beneficiaries.

Download the latest DA Form 5441-6 PDF here:
https://armypubs.army.mil/pub/eforms/DR_a/pdf/A5441_6.pdf

What Is DA Form 5441-6 Used For?

This form supports the Army’s Clinical Quality Management Program under AR 40-68. It provides a structured evaluation of an optometrist’s abilities in diagnosis, management, and specific procedures. Department/service chiefs use it during initial privileging, reappraisal, renewal, or focused reviews.

Evaluators rate each privilege as:

  • Acceptable
  • Unacceptable (must explain in Section II – Comments)
  • Not Applicable

Ratings directly influence privilege approval codes (cross-referenced with DA Form 5440) and decisions on medical staff appointment or reappointment.

Key Sections of DA Form 5441-6

Section I – Department/Service Chief Evaluation covers two main categories:

1. Diagnosis and Management of:

  • Refractive error problems
  • Binocularity problems
  • Accommodative problems
  • Low-vision problems
  • Developmental and perceptual problems
  • Contact lens problems
  • Diseases and disorders of the visual system, eye, and associated structures
    • Ordering laboratory and diagnostic imaging tests
    • Prescribing topical medications (allergies, infections, inflammation, glaucoma, pain)
    • Prescribing oral medications (same categories)
    • Refilling expired ophthalmic prescriptions

2. Procedures/Skills (selected examples):

  • Intermediate/comprehensive eye exams (new/established patients)
  • Determination of refractive state
  • Gonioscopy
  • Sensorimotor examination
  • Orthoptic/pleoptic training
  • Contact lens fitting for disease treatment
  • Visual field examination
  • Serial tonometry
  • Scanning computerized ophthalmic diagnostic imaging
  • Extended ophthalmoscopy
  • Ocular photography
  • Prescription and fitting of contact lenses (including aphakia)
  • Low vision aid evaluation
  • Removal of superficial or embedded corneal/conjunctival foreign bodies
  • Corneal epithelium procedures
  • Lacrimal punctum procedures (plug, dilation, probing, irrigation)
  • Ophthalmic ultrasound (A/B scan)
  • Electrodiagnostic testing (EOG/ERG)
  • Pachymetry
  • Correction of trichiasis (epilation)

The form emphasizes demonstrated patient management abilities and technical competence aligned with optometric scope of practice.

Who Needs DA Form 5441-6?

  • Army optometrists (active duty, reserve, civilian, or contract) in military hospitals, clinics, or deployed settings.
  • Providers applying for initial clinical privileges.
  • Those undergoing periodic recredentialing (typically every 2 years).
  • Optometrists in performance improvement or peer review processes.

Why Clinical Privileging Matters in the Army?

AR 40-68 requires rigorous credentialing to maintain high standards of care, support patient safety, and comply with DOD and statutory requirements (e.g., 10 USC 1094 and 1102). Proper privileging protects both providers and patients while enabling optometrists to deliver comprehensive primary eye care, including diagnosis, treatment, co-management of surgical cases, and identification of systemic conditions.

In military optometry, providers often handle:

  • Routine vision care for troops
  • Deployment-related eye injuries
  • Management of ocular diseases with topical/oral therapeutics
  • Pre- and post-operative care

How to Complete DA Form 5441-6?

  1. Fill in provider details (Name, Rank, Period of Evaluation, Facility).
  2. The evaluator (usually the Department Chief) reviews performance.
  3. Enter privilege approval codes.
  4. Rate each item and provide comments for any “Unacceptable” ratings.
  5. Sign and date; forward to the credentials office for review by the Executive Committee of the Medical Staff.

Previous editions are obsolete—always use the February 2004 version available from Army Publishing Directorate.

Tips for Army Optometrists

  • Maintain detailed records of procedures, continuing education, and patient outcomes.
  • Stay current with state licensure (unrestricted) and board certifications.
  • Document competence through proctoring, peer reviews, and ongoing professional practice evaluation (OPPE).
  • Review AR 40-68 thoroughly for full credentialing processes.

Related Resources:

  • AR 40-68: Clinical Quality Management (full regulation)
  • Army Publishing Directorate (armypubs.army.mil) for all DA Forms
  • DOD Medical Privilege Lists for Optometry (service-specific guidance)

This form plays a vital role in ensuring qualified optometric care across the U.S. Army. For official use, download directly from the Army site and consult your local credentials office or Medical Staff for guidance.