DA Form 5754. Malpractice History and Clinical Privileges Questionnaire

DA Form 5754, titled Malpractice History and Clinical Privileges Questionnaire, is used for medical professionals seeking clinical privileges within the Department of the Army. It serves as a comprehensive questionnaire to assess the medical professional's history of malpractice and suitability for clinical privileges.

The form includes sections where medical professionals provide information about their malpractice history, legal actions, licensure status, clinical training, and professional qualifications. It may also include sections for references and supporting documentation.

Important fields in this form encompass malpractice history, legal actions, and clinical training. Accurate completion of the form is crucial for evaluating the professional's eligibility for clinical privileges and ensuring patient safety.

Application Example: A medical doctor applying for clinical privileges at an Army hospital completes DA Form 5754, providing information about their past malpractice history, any legal actions, and their clinical training. The form aids in the review process to determine whether the doctor is suitable for practicing within the Army medical system.

No additional documents are typically needed to complete this form.

Related Form: SF-86 - Questionnaire for National Security Positions. This form is used to gather background information for security clearance purposes, which may be required for medical professionals with clinical privileges.