Get U.s. Dod Form Dod-da-5374 - U.s. Federal Forms

Filling out the U.S. DOD Form Dod-da-5374 can seem daunting, but with clear guidance, you can navigate the process smoothly. This guide provides step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to fill out the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the provider's name in the designated field, making sure to include their last name, first name, and middle initial.
3. Input the rank or grade of the provider in the next section, followed by their Social Security Number (SSN).
4. Specify the period of evaluation by filling in the 'FROM' and 'TO' dates in the YYYYMMDD format.
5. In the next section, indicate the department or service associated with the provider along with the facility's name and address, including the city, state, and ZIP code.
6. Select the purpose of evaluation, choosing from options like initial privileges, renewal of privileges, or modification of privileges.
7. For activity data, provide the average number of patients per month in various categories such as ambulatory care visits, emergency care visits, surgical procedures, etc.
8. Answer questions regarding the provider's health status and whether it should be considered in awarding privileges.
9. Evaluate the provider's attendance, participation in professional activities, and interpersonal skills with both patients and staff.
10. Complete the clinical performance profile by providing quantitative data related to antibiotic usage, surgical case reviews, and other related assessments.
11. In the performance evaluation section, check the appropriate rating for several competencies such as basic professional knowledge and patient management skills.
12. Use the comments section to elaborate on any unacceptable ratings or additional remarks regarding the provider's performance.
13. Fill in the date of evaluation, name, grade, title, and signature of the evaluator.
14. Indicate whether the provider reviewed the form after completion by selecting 'YES' or 'NO'.
15. Finally, save any changes made, and ensure you download or print the form for your records.

Complete your U.S. DOD Form Dod-da-5374 online today for a seamless filing experience.