Which form is this? DA Form 5754, official title MALPRACTICE HISTORY AND CLINICAL PRIVILEGES QUESTIONNAIRE, used to malpractice history and clinical privileges questionnaire. That is the whole answer in one sentence. What follows explains the version, the file and the entries.
Which edition is on this page? The one dated 04/01/2009, status ACTIVE. On army forms the edition date is the version, printed on the page itself so any copy can be checked.
Who fills it out, and how long does it take? The individual named in the entries fills it, or a records clerk fills it on that person's behalf. Length is 2 page(s) with about 200 entry fields, which is the honest measure of the work involved. Who owns the form and when it is raised comes from TSG and AR 40-68 respectively.
What the form asks for
- AddA
- AddA_1
- AddA_2
- AddA_3
- AddA_4
- AddA_5
- AddB
- AddB_1
- AddB_2
- AddB_3
- AddB_4
- AddB_5
- Bday
- Comments
- ContentArea1
- ContentArea2
- Corps
- DATE
- Facility
- FromB
- FromB_1
- FromB_2
- FromB_3
- FromB_4
Download the form
What file types are offered? PDF, XFDL. The page image is the same in every one of them; only the way you complete it changes from format to format.
Should I take the fillable pdf or the printable one? Take the fillable version if you will type, since its entry areas respond to the keyboard and hold what you enter. Take the printable version if you will write by hand — it is the same blank form as a flat page image. The finished result looks the same either way.
What do I open a pdf with? Any current browser will display one, and any dedicated reader will do better. For fillable use the reader is the safer choice, because some browser viewers accept typing and then discard it when the tab closes. Test one field and one save before committing. What opens an xfdl file? Only the IBM Lotus Forms Viewer. The format is IBM Lotus Forms, carried by several Army systems, and no pdf reader or word processor will touch it.
Is it free? Yes, entirely. No registration stands between you and the file, and what arrives is exactly what the publisher released.
What goes in first? The heading block — your name exactly as official records show it, then identification number, then organisation, then the date you prepared the form. Is the order important? It is, because those four entries become the index for the finished record, and an error there is the one mistake that hides the document from everyone looking for it.
How should you work through the entry fields? With the tab key. It follows the order the form was constructed in, which is usually the order the page reads, so nothing gets passed over. Do check boxes work the same way? They are clicked rather than tabbed into. In an exclusive group, a second click elsewhere clears your first choice, as intended.
What happens if your answer is too long for the field? It prints cut off. A single-line field does not wrap, so text running past the edge stays readable on screen and then disappears at the margin on paper. What do you do instead? Move it to the remarks area or onto a continuation sheet. And a field that does not apply to you? Mark it as not applicable rather than leaving it blank — an empty box tells the reviewer nothing about whether you read the question.
When do you sign? Last, after every other entry is settled. Until the signature is applied the document is a draft, however complete it looks. What if more than one signature is required? Reviewing official, approving authority and witness sign in the order the blocks print, and each dates the form on the day of signing rather than the day it was prepared. What goes wrong most often? Mandatory fields left empty, transposed digits in identification numbers, dates with day and month reversed, and old entries surviving in a working copy that was reused instead of a fresh blank form.
What does the Privacy Act notice tell you? The legal authority behind the collection, what the information is for, the routine uses it may be put to, and whether disclosure is compulsory. When is the right moment to read it? Before completing the personal entries, at the point the statement appears. What follows from it? Your finished copy contains personal data, so store and send it the way your office handles that category.
Where do you send it? To the destination the prescribing directive names, which may be a specific office, the unit administrative channel, or the individual's file. Is a copy worth keeping? Always, and taken before submission. How long does the receiving office keep it? For the period the records schedule for the series prescribes, regardless of local custom.
How do you find related forms? By series and number. Documents in the DA series sharing a proponent or a prescribing directive are commonly used together, and a form cited on the face of another usually goes forward with it. When should you gather them? Before submission — continuation sheets, cover sheets and transmittal documents belong in the package from the start.
When is an edition replaced? When the proponent revises the form and publishes a new edition date. What should you do with a copy kept on your own machine? Check its date against the edition in force before reusing it. Does the change reach backwards? It does not; work already completed on an earlier edition remains valid as filed.
Is this an official Department of the Army site? No. It is an independent site distributing reproductions of published Department of the Army documents for download, with no authority to issue forms. Does it guarantee acceptance of anything you submit? It does not, and nothing on the page is legal advice. Who should you ask instead? TSG or your servicing administrative office, whenever an entry, a requirement or your eligibility is in doubt.
Questions and answers
- What is DA Form 5754?
- MALPRACTICE HISTORY AND CLINICAL PRIVILEGES QUESTIONNAIRE
- Which edition is current?
- 04/01/2009
- Who is responsible for this form?
- TSG
- In which formats can it be downloaded?
- PDF, XFDL, PDF
Publisher notes
- 42-ITEM ONLY PRODUCED IN ELECTRONIC MEDIA
- 14-REQUIRES PRIVACY ACT STATEMENT (AR 340-21),