MI) 3. FACILITY INSTRUCTIONS: PROVIDER: Enter the appropriate provider code in the column marked "REQUESTED". Each category and/or individual privilege listed must be coded. For procedures listed, line through and initial any criteria/applications that do not apply. Your signature is required at the end of Section I. Once approved, any revisions or corrections to this list of privileges will require you to submit a new DA Form 5440. SUPERVISOR: Review each category and/or individual privilege.
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How to fill out the U.S. DOD Form Dod-da-5440-16 online
This guide provides a step-by-step approach to filling out the U.S. DOD Form Dod-da-5440-16, which is used for delineation of clinical privileges for nurse practitioners. Whether you are a provider or a supervisor, this document is essential for recognizing clinical competencies and authorizations.
Follow the steps to successfully complete the form online.
- Click ‘Get Form’ button to access the form and open it in your preferred online editor.
- Begin by entering the name of the provider in the 'NAME OF PROVIDER' field, including the last name, first name, and middle initial.
- Next, input the rank or grade of the provider in the 'RANK/GRADE' field.
- Fill in the facility name in the 'FACILITY' field to identify where the privileges will be applied.
- In Section I, enter the appropriate provider codes in the 'REQUESTED' column, crossing out and initialing any privileges not applicable.
- If you are the provider, sign at the end of Section I to validate your requested privileges.
- If you are the supervisor, review the provider's requested privileges and enter the appropriate approval codes in the 'APPROVED' column.
- Ensure that the supervisor provides their signature in Section II, indicating the overall recommendation.
- In Section III, the credentials committee must indicate the recommendation status and provide the committee chairperson’s signature.
- After filling out all sections, you can save your changes, download, print, or share the completed form as needed.
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What all do you need for a leave form Army?
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Every command will have its own procedures for requesting leave. It may involve a paper or electronic leave request form sometimes called a “leave chit.” The command will then approve or deny the leave request.
How do I access Army pubs?
For a complete listing of Army publications and forms, please visit https://armypubs.army.mil/.
How do I get a DA 31 form?
How to rapidly redact Request and Authority for Leave. DA FORM 31, SEP 2022 online Sign up and sign in. Create a free account, set a secure password, and go through email verification to start working on your forms. Add a document. ... Make adjustments to the template. ... Get your paperwork done.
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What is DA 31 form? The purpose of the DA 31 form is to authorize military leave; document the start and stop of such leave; record address and telephone number where a soldier may be contacted in case of an emergency during leave; and certify leave days chargeable to a soldier's leave account.
Where can I download Army forms?
Visit http://.e-publishing.af.mil/ To access their Forms.
What is a DA 31 form military?
The purpose of the DA 31 form is to authorize military leave; document the start and stop of such leave; record address and telephone number where a soldier may be contacted in case of an emergency during leave; and certify leave days chargeable to a soldier's leave account.
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