DA Form 5441-39. Evaluation of Clinical Privileges - Nuclear Medicine

DA Form 5441-39 is intended for evaluating clinical privileges for Nuclear Medicine professionals. This form serves the crucial purpose of assessing and establishing the qualifications and requested privileges for practitioners specializing in utilizing radioactive materials for diagnostic and therapeutic purposes.

The form comprises sections where the nuclear medicine practitioner provides personal and professional details, including licenses, certifications, and qualifications specific to nuclear medicine practice. It requires outlining the requested clinical privileges, encompassing areas such as nuclear imaging studies, radionuclide therapies, and radiopharmaceutical administration.

Key fields in this form include the nuclear medicine practitioner's identification information, requested clinical privileges, and supporting documentation showcasing their expertise in nuclear medicine. Accurate completion of this form is vital to ensure that the practitioner is granted privileges aligned with their proficiency in utilizing radioactive materials for medical applications.

Application Example: A licensed nuclear medicine technologist joining a military medical facility would utilize DA Form 5441-39 to request clinical privileges. By accurately completing the form and providing necessary documentation, the practitioner's proficiency in conducting nuclear imaging studies and administering radiopharmaceuticals 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 5441-37, 5441-38, 5441-4, and 5441-40 are related forms intended for different clinical privilege evaluation processes.