Get U.s. Dod Form Dod-da-5441-16 - U.s. Federal Forms

Filling out the U.S. DOD Form Dod-da-5441-16 is essential for evaluating clinical privileges for nurse practitioners. This guide will walk you through each section of the form to ensure a comprehensive and accurate submission.

Follow the steps to complete the form accurately and efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. In the first section, enter the name of the provider in the format of last name, first name, middle initial.
3. Indicate the rank or grade of the provider next to the name.
4. Fill in the period of evaluation with the start date and end date, using the format YYYYMMDD.
5. Specify the department or service related to the provider's clinical privileges.
6. Provide the facility's name and complete address, including city, state, and ZIP code.
7. In Section I, evaluate core privileges. Tick the appropriate boxes under Acceptable, Unacceptable, or Not Applicable for each privilege listed.
8. If any privilege is marked as unacceptable, provide explanations in Section II - Comments.
9. In Section II, include the name and title of the evaluator, and ensure to sign and date the form.
10. Review all sections for accuracy before proceeding to save your changes, download, print, or share the completed form.

Complete the U.S. DOD Form Dod-da-5441-16 online today for a streamlined evaluation process.