DA Form 5440-53. Delineation of Clinical Privileges - Occupational Medicine

DA Form 5440-53 is designed for the delineation of clinical privileges within the field of Occupational Medicine. This form facilitates the documentation and evaluation of a medical practitioner's qualifications and requested privileges related to workplace health and occupational health assessments.

The form comprises sections where the practitioner provides their personal and professional details, including medical licenses, certifications, and qualifications. It also requires outlining the requested clinical privileges, covering areas such as occupational health evaluations, workplace safety assessments, and related medical services.

Important fields in this form include the practitioner's identifying information, requested clinical privileges, and supporting documentation demonstrating their expertise in occupational medicine. Accurate completion of this form is vital to ensure that the practitioner is granted clinical privileges aligned with their proficiency in occupational health management.

Application Example: A certified occupational medicine physician joining a military medical facility would utilize DA Form 5440-53 to request clinical privileges. By accurately completing the form and submitting necessary documentation, the practitioner's proficiency in workplace health assessments is evaluated, enabling the medical facility to grant appropriate privileges for managing occupational health concerns.

No additional documents are explicitly mentioned as required for filling this form.

Related Form: DA Form 5440-52, 5440-54, 5440-55, and 5440-56 are related forms intended for different medical specialties, each catering to specific clinical privileges.