DA Form 5441-36. Evaluation of Clinical Privileges - Audiology

DA Form 5441-36 is intended for evaluating clinical privileges for Audiology professionals. This form serves the crucial purpose of assessing and establishing the qualifications and requested privileges for practitioners specializing in diagnosing and treating hearing and balance disorders.

The form comprises sections where the audiologist provides personal and professional details, including licenses, certifications, and qualifications specific to audiology practice. It requires outlining the requested clinical privileges, encompassing areas such as hearing assessments, balance evaluations, and hearing aid fittings.

Key fields in this form include the audiologist's identification information, requested clinical privileges, and supporting documentation showcasing their expertise in audiology. Accurate completion of this form is vital to ensure that the practitioner is granted privileges aligned with their proficiency in diagnosing and treating hearing and balance disorders.

Application Example: A licensed audiologist joining a military medical facility would utilize DA Form 5441-36 to request clinical privileges. By accurately completing the form and providing necessary documentation, the practitioner's proficiency in hearing assessments and balance evaluations is evaluated, enabling the medical facility to grant appropriate privileges.

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

Related Form: DA Form 5441-32, 5441-33, 5441-34, and 5441-35 are related forms intended for different clinical privilege evaluation processes.