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U.S. Army (DA) Forms in Word: DA 5000-5702 (p. 6 of 12)
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LINKS TO DA PAGES: DA 2 to 1059-2, DA 1085-R to 1918 DA 1928 to 2985, DA 3020-R to 3999-3-R, DA 4005 to 4999, DA 5000-R to 5703, DA 5704-R to 7223 DA 7223-1 to 7405 DA 7406 to 7496 DA 7500 to 8028 , and New DA Forms (new from 7/04 - 1/06), Army GPO, JCP, OF, OGE, OPM, and SGVL Forms, Army DSC Forms
FORM NO. |
FORM TITLE |
Price |
BUY NOW IN WORD |
| DA 5000-R | APPLICANT'S INTERVIEW REPORT-JUDGE ADVOCATE GENERAL'S CORPS | $4.99 |
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| DA 5006 | AUTHORIZATION FOR DISCLOSURE OF INFORMATION | $4.99 |
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| DA 5007A | MEDICAL RECORD - ALLERGY IMMUNOTHERAPY RECORD | $4.99 |
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| DA 5007B | MEDICAL RECORD - ALLERGY IMMUNOTHERAPY RECORD | $4.99 |
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| DA 5008 | TELEPHONE MEDICAL ADVICE/CONSULTATION RECORD | $4.99 |
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| DA 5009 | RELEASE AGAINST MEDICAL ADVICE | $4.99 |
|
| DA 5011-R | TRAINING EVALUATION SUMMARY | $4.99 |
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| DA 5016-R | CHRONOLOGICAL RECORD OF MILITARY SERVICE | $4.99 |
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| DA 5017 | CIVILIAN EMPLOYEE CONSENT STATEMENT | $4.99 |
|
| DA 5018-R | ADAPCP CLIENT'S CONSENT STATEMENT FOR RELEASE OF TREATMENT INFORMA- TION | $4.99 |
|
| DA 5019 | CONDITION OF EMPLOYMENT FOR CERTAIN CIVILIAN POSITIONS IDENTIFIED CRITICAL UNDER THE DEPARTMENT OF THE ARMY DRUG-FREE FEDERAL WORKPLACE PROGRAM | $4.99 |
|
| DA 5026-R | RECORD OF CERTIFICATION SMALL ARMS SHIPMENT CONTROL | $4.99 |
|
| DA 5027-R | MEDCASE PROGRAM REQUIREMENT | $4.99 |
|
| DA 5028-R | MEDCASE SUPPORT AND TRANSMITTAL FORM | $4.99 |
|
| DA 5030 | ENGINEER DIVER TRAINING APPLICATION | $4.99 |
|
| DA 5032-R | FIELD ARTILLERY DELIVERED MINEFIELD PLANNING SHEET | $4.99 |
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| DA 5033-R | LIMITED SURFACE OBSERVATION | $4.99 |
|
| DA 5034-R | PROJECT DOCUMENTATION SPACE ALLOWANCES WORKSHEET | $4.99 |
|
| DA 5051-10-R | MAINTENANCE TEST FLIGHT MANEUVERS GRADE SLIP (OV/RV-1) | $4.99 |
|
| DA 5051-11-R | MAINTENANCE TEST FLIGHT MANEUVERS GRADE SLIP (AH-64) | $4.99 |
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| DA 5051-12-R | MAINTENANCE TEST FLIGHT MANEUVERS GRADE SLIP (OH-58D) | $4.99 |
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| DA 5051-1-R | MAINTENANCE TEST FLIGHT MANEUVERS GRADE SLIP (OH-58A/C) | $4.99 |
|
| DA 5051-2-R | MAINTENANCE TEST FLIGHT MANEUVERS GRADE SLIP (UH-1) | $4.99 |
|
| DA 5051-4-R | MAINTENANCE TEST FLIGHT MANEUVERS GRADE SLIP (AH-1) | $4.99 |
|
| DA 5051-5-R | MAINTENANCE TEST FLIGHT MANEUVERS GRADE SLIP (CH-47) | $4.99 |
|
| DA 5051-7-R | MAINTENANCE TEST FLIGHT MANEUVERS GRADE SLIP (OH-6) | $4.99 |
|
| DA 5051-9-R | MAINTENANCE TEST FLIGHT MANEUVERS GRADE SLIP (CH-54) | $4.99 |
|
| DA 5056 | ACTEDS INTERN WORK YEAR REQUIREMENTS | $4.99 |
|
| DA 5070-R | JUSTIFICATION STATEMENT FOR .0015 CONTINGENCY FUNDS | $4.99 |
|
| DA 5071-R | FUND CUSTODIAN RECEIPT CONTROL AND CASH ACCOUNTABILITY JOURNAL | $4.99 |
|
| DA 5072 | EMERGENCY ACTION STATEMENT | $4.99 |
|
| DA 5073 | MAGNETIC COMPASS DEVIATION TABLE | $4.99 |
|
| DA 5074-1-R | RECORD OF AWARD OF ENTRY GRADE CREDIT (HEALTH SERVICES OFFICERS) | $4.99 |
|
| DA 5074-R | RECORD OF AWARD OF ENTRY GRADE CREDIT (MEDICAL AND DENTAL OFFICERS) | $4.99 |
|
| DA 5075-R | ARTILLERY SURVEY CONTROL POINT | $4.99 |
|
| DA 5095-A-R | FIRE MISSION SUMMARY (CLASSIFIED WHEN FILLED IN) | $4.99 |
|
| DA 5095-B-R | FIRE PLAN SUMMARY | $4.99 |
|
| DA 5100-R | REQUEST FOR SUBSISTENCE PAYROLL DEDUCTION | $4.99 |
|
| DA 5105 | JANITORIAL STANDARDS CHECKLIST | $4.99 |
|
| DA 5106 | MISSION SUPPORT PLAN (MSP) | $4.99 |
|
| DA 5108-R | DOCUMENTATION FOR PRODUCTIVITY CAPITAL INVESTMENT PROGRAMS | $4.99 |
|
| DA 5109 | REQUEST TO SUPERIOR TO EXERCISE ARTICLE 15, UCMJ, JURISDICTION | $4.99 |
|
| DA 5110 | ARTICLE 15-RECONCILIATION LOG | $4.99 |
|
| DA 5111 | SUMMARY COURT-MARTIAL RIGHTS NOTIFICATION/WAIVER STATEMENT | $4.99 |
|
| DA 5112 | CHECKLIST FOR PRETRIAL CONFINEMENT | $4.99 |
|
| DA 5117-R | REASSIGNMENT CONTROL SHEET | $4.99 |
|
| DA 5118 | REASSIGNMENT STATUS AND ELECTION STATEMENT | $4.99 |
|
| DA 5121-R | OVERSEAS TOUR ELECTION STATEMENT | $4.99 |
|
| DA 5123 | IN- AND OUT-PROCESSING RECORDS CHECKLIST | $4.99 |
|
| DA 5123-1 | IN-PROCESSING PERSONNEL RECORD | $4.99 |
|
| DA 5137-R | APPLICATION FOR VOLUNTARY MOBILIZATION PREASSIGNMENT | $4.99 |
|
| DA 5138-R | SEPARATION ACTION CONTROL SHEET | $4.99 |
|
| DA 5142-R | THE INSPECTOR GENERAL ACTION REQUEST SYSTEM (IGARS)DATA | $4.99 |
|
| DA 5146-R | ASPHALT PAVEMENT INSPECTION SHEET | $4.99 |
|
| DA 5147-R | SECTION EVALUATION SUMMARY | $4.99 |
|
| DA 5148-R | PRESENT WORTH COMPUTATION | $4.99 |
|
| DA 5149-1-R | BRANCH IDENTIFICATION SUMMARY CONTINUATION SHEET | $4.99 |
|
| DA 5149-R | BRANCH IDENTIFICATION SUMMARY | $4.99 |
|
| DA 5150-R | SECTION IDENTIFICATION RECORD | $4.99 |
|
| DA 5151-R | SECTION PAVEMENT STRUCTURE RECORD | $4.99 |
|
| DA 5152-R | SECTION MATERIALS PROPERTIES RECORD | $4.99 |
|
| DA 5153-R | SECTION TRAFFIC RECORD | $4.99 |
|
| DA 5155-R | BRANCH MAINTENANCE & REPAIR REQUIREMENTS | $4.99 |
|
| DA 5156-R | SECTION MAINTENANCE AND REPAIR RECORD | $4.99 |
|
| DA 5159 | INVENTORY OF ARMY PERSONNEL TEST MATERIAL | $4.99 |
|
| DA 5160 | TEST ADMINISTRATION STATEMENT | $4.99 |
|
| DA 5161-1-R | FOOD ESTABLISHMENT SANITATION INSPECTION - REMARKS FORM | $4.99 |
|
| DA 5161-R | COMPREHENSIVE FOOD ESTABLISHMENT INSPECTION | $4.99 |
|
| DA 5162-R | ROUTINE FOOD ESTABLISHMENT INSPECTION REPORT | $4.99 |
|
| DA 5163-R | NONAPPROPRIATED FUND CENTRAL PAYROLL SYSTEM TIPS, SERVICE CHARGES AND MEALS REPORT | $4.99 |
|
| DA 5164-R | HANDS-ON EVALUATION | $4.99 |
|
| DA 5165-R | FIELD EXPEDIENT SQUAD BOOK | $4.99 |
|
| DA 5167 | INCENTIVE AWARDS NOMINATION AND APPROVAL - NONAPPROPRIATED FUNDS | $4.99 |
|
| DA 5168-R | SAFETY CLEARANCE ORDER (ELECTRICAL FACILITIES) | $4.99 |
|
| DA 5170-R | PROPONENT MANAGEMENT INFORMATION REQUIREMENT REVIEW | $4.99 |
|
| DA 5172-R | REQUEST, AUTHORIZATION, AND REPORT OF OVERTIME | $4.99 |
|
| DA 5178-R | PROJECT DEVELOPMENT IDENTIFIER (PDI) AND PROJECT DEVELOPMENT SKILL IDENTIFIER (PDSI) | $4.99 |
|
| DA 5179 | MEDICAL RECORD PREOPERATIVE/POSTOPERATIVE NURSING DOCUMENT | $4.99 |
|
| DA 5179-1 | MEDICAL RECORD INTRAOPERATIVE DOCUMENT | $4.99 |
|
| DA 5179-1 IMAGE 1/2 | MEDICAL RECORD INTRAOPERATIVE DOCUMENT | $4.99 |
|
| DA 5179-1 IMAGE 2/2 | MEDICAL RECORD INTRAOPERATIVE DOCUMENT | $4.99 |
|
| DA 5181 | SCREENING NOTE OF ACUTE MEDICAL CARE | $4.99 |
|
| DA 5182-R | SOIL SUCTION, WATER CONTENT, AND SPECIFIC VOLUME | $4.99 |
|
| DA 5184 | CONSUMER COMPLAINT | $4.99 |
|
| DA 5187 | APPLICATION FOR RESPITE CAREGIVERS | $4.99 |
|
| DA 5188 | MEDICAL REPORT ON APPLICANT FOR CERTIFICATION TO PROVIDE CARE FOR CHILDREN OR ADULTS WITH DISABILITIES | $4.99 |
|
| DA 5189 | APPLICATION FOR RESPITE CARE FOR CHILDREN AND ADULTS WITH DISABILITIES | $4.99 |
|
| DA 5190 | CLINICIAN'S INFORMATION | $4.99 |
|
| DA 5191 | INFORMATION ON INDIVIDUAL WITH DISABILITY | $4.99 |
|
| DA 5192 | FAMILY IDENTIFICATION SHEET FOR A CHILD RECEIVING SERVICE | $4.99 |
|
| DA 5193 | CHILD'S FACE AND WHEREABOUTS SHEET | $4.99 |
|
| DA 5195 | HEALTH DATA | $4.99 |
|
| DA 5202-R | INTERNATIONL CONTROL IMPROVEMENT ACTIVITIES REPORT | $4.99 |
|
| DA 5203 | DODIC MASTER/LOT LOCATOR RECORD | $4.99 |
|
| DA 5212-R | PDF SCAN PROJECT | $4.99 |
|
| DA 5219-R | CHILD DEVELOPMENT SERVICES (CDS) FAMILY CHILD CARE (FCC) PROVIDER APPLICATION | $4.99 |
|
| DA 5220-R | CHILD DEVELOPMENT SERVICES (CDS) FAMILY CHILD CARE (FCC) PROVIDER BACKGROUND CLEARANCE REQUEST | $4.99 |
|
| DA 5221-R | CHILD DEVELOPMENT SERVICES (CDS) FAMILY CHILD CARE (FCC) CERTIFICATION DENIAL/ REVOCATION | $4.99 |
|
| DA 5222-R | CHILD DEVELOPMENT SERVICES (CDS) SPONSOR CONSENT | $4.99 |
|
| DA 5223-R | CHILD DEVELOPMENT SERVICES (CDS) CHILD HEALTH ASSESSMENT | $4.99 |
|
| DA 5224-R | CHILD DEVELOPMENT SERVICES (CDS) CHILD AND FAMILY PROFILE | $4.99 |
|
| DA 5225-R | CHILD DEVELOPMENT SERVICES (CDS) MEDICAL DISPENSATION RECORD | $4.99 |
|
| DA 5226-R | CHILD DEVELOPMENT SERVICE (CDS) SPONSOR/ PROGRAM AGREEMENT | $4.99 |
|
| DA 5227 | DA EMPLOYMENT AND MOBILITY AGREEMENT FOR DA ACTEDS INTERNS | $4.99 |
|
| DA 5228 | DEPARTMENT OF THE ARMY PRESIDENTIAL MANAGEMENT INTERN MOBILITY AGREEMENT | $4.99 |
|
| DA 5234-R | OER CONTROL LOG | $4.99 |
|
| DA 5235-R | VOLUNTER STATEMENT FOR THE ENLISTED CLUB MANAGEMENT CAREER PROGRAM (MOS OOJ) | $4.99 |
|
| DA 5237-R | PSNCO EER SUSPENSE ROSTER | $4.99 |
|
| DA 5239-R | 75-, 175- AND 300-METER DOWN RANGE FEEDBACK SCORECARD | $4.99 |
|
| DA 5239-R IMAGE 1/2 | 75-, 175- AND 300-METER DOWN RANGE FEEDBACK SCORECARD | $4.99 |
|
| DA 5239-R IMAGE 2/2 | 75-, 175- AND 300-METER DOWN RANGE FEEDBACK SCORECARD | $4.99 |
|
| DA 5241-R | SINGLE AND MULTIPLE TARGETS FIELD FIRING SCORECARD | $4.99 |
|
| DA 5246-R FILE 1/3 | ARMY CHILD DEVELOPMENT SERVICES (CDS) REPORT | $4.99 |
|
| DA 5246-R FILE 2/3 | ARMY CHILD DEVELOPMENT SERVICES (CDS) REPORT | $4.99 |
|
| DA 5246-R FILE 3/3 | ARMY CHILD DEVELOPMENT SERVICES (CDS) REPORT | $4.99 |
|
| DA 5247-R | REQUEST FOR SECURITY DETERMINATION | $4.99 |
|
| DA 5248-R | REPORT OF UNFAVORABLE INFORMATION FOR SECURITY DETERMINATION | $4.99 |
|
| DA 5250 | ROTC SCHOLARSHIP - RESERVE FORCES DUTY | $4.99 |
|
| DA 5251-R | CONAUTH KEY MANAGEMENT WORKSHEET | $4.99 |
|
| DA 5252-R | STATEMENT - EVIDENCE OF CITIZENSHIP STATUS | $4.99 |
|
| DA 5257-R | STINGER GUNNER PERFORMANCE EVALUATION SHEET | $4.99 |
|
| DA 5258-R | REDEYE GUNNER PERFORMANCE EVALUATION SHEET | $4.99 |
|
| DA 5261-1-R | SELECTED RESERVE INCENTIVE PROGRAM - EDUCATIONAL ASSISTANCE ADDENDUM | $4.99 |
|
| DA 5261-2-R | SELECTED RESERVE INCENTIVE PROGRAM - REENLISTMENT/EXTENSION BONUS ADDENDUM | $4.99 |
|
| DA 5261-3-R | SELECTED RESERVE INCENTIVE PROGRAM - AFFILIATION BONUS ADDENDUM | $4.99 |
|
| DA 5261-4-R | STUDENT LOAN REPAYMENT PROGRAM ADDENDUM | $4.99 |
|
| DA 5261-5-R | SELECTED RESERVE INCENTIVE PROGRAM - USAR PRIOR SERVICE ENLISTMENT BONUS ADDENDUM | $4.99 |
|
| DA 5261-R | SELECTED RESERVE INCENTIVE PROGRAM - ENLISTMENT BONUS ADDENDUM | $4.99 |
|
| DA 5274-R | STANDARD INPUT DATA COMPUTATIONS | $4.99 |
|
| DA 5275-R | TIME STUDY RECORD | $4.99 |
|
| DA 5276-R | PROGRAM MANAGEMENT DATA | $4.99 |
|
| DA 5277-R | OPERATIONAL AUDIT DATA | $4.99 |
|
| DA 5278-R1 | WORK SAMPLING RECORD | $4.99 |
|
| DA 5278-R2 | WORK SAMPLING RECORD | $4.99 |
|
| DA 5279-R | MANPOWER STANDARD AND TABLE | $4.99 |
|
| DA 5286 | INDIVIDUAL BASIC TRAINING (BT), ADVANCED INDIVIDUAL TRAINING (AIT), ONE STATION UNIT TRAINING (OSUT) | $4.99 |
|
| DA 5286-1 | INDIVIDUAL TRAINING RECORD (CONTINUATION SHEET),BASIC TRAINING (BT), ADVANCED INDIVIDUAL TRAINING (AIT), ONE STATION UNIT TRAINING (OSUT) | $4.99 |
|
| DA 5289-R | TRAVELING PURCHASE REQUEST | $4.99 |
|
| DA 5297 | ABSTRACT OF VENDOR DELIVERIES | $4.99 |
|
| DA 5298 | OPERTIONAL RATIONS ACCOUNTABILITY | $4.99 |
|
| DA 5303-R | VOLUNTEER AGREEMENT AFFIDAVIT | $4.99 |
|
| DA 5304-R | FAMILY CARE PLAN COUNSELING CHECKLIST | $4.99 |
|
| DA 5305-R | FAMILY CARE PLAN | $4.99 |
|
| DA 5310-R | FIREFINDER FRIENDLY FIRE | $4.99 |
|
| DA 5313-1-R | NONAPPROPRIATED FUND PAYABLE/DISBURSEMENT VOUCHER CONTINUATION SHEET | $4.99 |
|
| DA 5313-R | NONAPPROPRIATED FUND PAYABLE/DISBURSEMENT VOUCHER | $4.99 |
|
| DA 5315-R | US ARMY ADVANCED EDUCATION FINANCIAL ASSISTANCE RECORD | $4.99 |
|
| DA 5327 | BONA FIDE DEPENDENT DECLARATION - MILITARY | $4.99 |
|
| DA 5328 | BONA FIDE DEPENDENT DECLARATION (CIVILIAN) | $4.99 |
|
| DA 5329 | ESCORT REPORT | $4.99 |
|
| DA 5330 | RELEASE OF REMAINS FOR LOCAL DISPOSITION (OCONUS) | $4.99 |
|
| DA 5331-R | DESTINATION DEALER'S CERTIFICATION OF TURN-IN OF RENTAL VEHICLE | $4.99 |
|
| DA 5339 | OCS APPLICANT'S COMMANDERS EVALUATION SHEET | $4.99 |
|
| DA 5353-R | BANK RECONCILIATION WORKSHEET | $4.99 |
|
| DA 5356-R | PROGRAM WORKSHEET (SB-3614A(V)/TT) | $4.99 |
|
| DA 5359-R | LONG-RANGE SPECIAL ASSIGNMENT AIRLIFT MISSION (SAAM) FLYING HOUR REQUIREMENTS | $4.99 |
|
| DA 5367-R | PERSONNEL STATUS REPORT | $4.99 |
|
| DA 5368 | QUICK FIRE PLAN | $4.99 |
|
| DA 5369-R | ROTATION AGREEMENT - EMPLOYEES RECRUITED FROM THE UNITED STATES | $4.99 |
|
| DA 5370-R | ROTATION AGREEMENT - EMPLOYEES RECRUITED LOCALLY IN FOREIGN AREA | $4.99 |
|
| DA 5371-R | ROTATION AGREEMENT - EMPLOYEES RECRUITED FROM THE US TERRITORIES AND POSSESSIONS | $4.99 |
|
| DA 5372-R | ORIENTATION STATEMENT | $4.99 |
|
| DA 5373-R | REQUEST FOR PROCESSING OF OVERSEAS SELECTEE | $4.99 |
|
| DA 5374 | PERFORMANCE ASSESSMENT | $4.99 |
|
| DA 5376-R1 | INDIVIDUAL TRAINING EVALUATION RECORD | $4.99 |
|
| DA 5376-R2 | INDIVIDUAL TRAINING EVALUATION RECORD | $4.99 |
|
| DA 5377-R | FIRE AND EMERGENCY SERVICES TRAINING RECORD | $4.99 |
|
| DA 5378-R | FACILITY RESPONSE CARD | $4.99 |
|
| DA 5379-R | APPARATUS MAINTENANCE CHECKLIST | $4.99 |
|
| DA 5380-R | FIRE APPARATUS TEST RECORD | $4.99 |
|
| DA 5381-R | BUILDING - FIRE RISK MANAGEMENT SURVEY | $4.99 |
|
| DA 5382-R | HAZARD/DEFICIENCY INSPECTION RECORD | $4.99 |
|
| DA 5383-R | HOT-WORK PERMIT | $4.99 |
|
| DA 5384-R | WATER FLOW TEST | $4.99 |
|
| DA 5391-R | WORKLOAD MANAGEMENT SYSTEM FOR NURSING | $4.99 |
|
| DA 5394-1 | PRINTING FACILITY PRODUCTIVITY REPORT | $4.99 |
|
| DA 5396 | OVERSEAS TOUR EXTENSION INCENTIVE PROGRAM MONTHLY REPORT | $4.99 |
|
| DA 5402-R | BARBER/BEAUTY SHOP INSPECTION | $4.99 |
|
| DA 5409 | INOPERATIVE EQUIPMENT REPORT | $4.99 |
|
| DA 5410 | UNIT LEVEL DEADLINING PARTS REPORT | $4.99 |
|
| DA 5412-R | WAIVER OF COMPENSATION STATEMENT | $4.99 |
|
| DA 5413-R | CONSULTANT/EXPERT CERTIFICATE | $4.99 |
|
| DA 5414-R | ADMINISTRATIVE REEMPLOYMENT RIGHTS AGREEMENT | $4.99 |
|
| DA 5415 | GARRISON CATEFORY COMPETITION CHECKLIST | $4.99 |
|
| DA 5416 | FIELD CATEGORY COMPETITION CHECKLIST | $4.99 |
|
| DA 5417-R | Estimate Detail Summary Sheet | $4.99 |
|
| DA 5422-R | REQUEST FOR BULK FUND ORDER | $4.99 |
|
| DA 5425-R | APPLICANT/NOMINEE PERSONAL FINANCIAL STATEMENT | $4.99 |
|
| DA 5426-R | COMMANDER'S EVALUATION | $4.99 |
|
| DA 5427 | COMMANDER'S ASSESSMENT OF RECRUITER CANDIDATE - updated 11-06 | $4.99 |
|
| DA 5429-R | CONDUCT OF FIRE | $4.99 |
|
| DA 5433-R | VERIFICATION OF OVERSEAS EMPLOYMENT FOR NONCOMPETITIVE APPOINTMENT UNDER EO 12362 | $4.99 |
|
| DA 5434 | SPONSORSHIP PROGRAM COUNSELING AND INFORMATION SHEET | $4.99 |
|
| DA 5435-R | STATEMENT OF UNDERSTANDING - THE SELECTED RESERVE MONTGOMERY GI BILL(10 USC CHAPTER 1606) | $4.99 |
|
| DA 5440-1 | DELINEATION OF CLINICAL PRIVILEGES - DENTISTRY | $4.99 |
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| DA 5440-10 | DELINEATION OF CLINICAL PRIVILEGES - PSYCHIATRY | $4.99 |
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| DA 5440-11 | DELINEATION OF CLINICAL PRIVILEGES - CLINICAL PSYCHOLOGY | $4.99 |
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| DA 5440-12 | DELINEATION OF CLINICAL PRIVILEGES - DIAGNOSTIC RADIOLOGY | $4.99 |
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| DA 5440-13 | DELINEATION OF CLINICAL PRIVILEGES - GENERAL SURGERY | $4.99 |
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| DA 5440-14 | DELINEATION OF CLINICAL PRIVILEGES - NURSE ANESTHETIST | $4.99 |
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| DA 5440-15 | DELINEATION OF CLINICAL PRIVILEGES - CERTIFIED NURSE MIDWIFE | $4.99 |
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| DA 5440-16 | DELINEATION OF CLINICAL PRIVILEGES - NURSE PRACTITIONER | $4.99 |
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| DA 5440-18 | DELINEATION OF CLINICAL PRIVILEGES - PHYSICIAN ASSISTANT | $4.99 |
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| DA 5440-19 | DELINEATION OF CLINICAL PRIVILEGES - DIETETICS | $4.99 |
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| DA 5440-2 | DELINEATION OF CLINICAL PRIVILEGES - FAMILY PRACTICE | $4.99 |
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| DA 5440-20 | DELINEATION OF CLINICAL PRIVILEGES - OCCUPATIONAL THERAPY | $4.99 |
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| DA 5440-21 | DELINEATION OF CLINICAL PRIVILEGES - PHYSICAL THERAPY | $4.99 |
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| DA 5440-22 | DELINEATION OF CLINICAL PRIVILEGES | $4.99 |
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| DA 5440-23 | DELINEATION OF CLINICAL PRIVILEGES - EMERGENCY MEDICINE | $4.99 |
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| DA 5440-24 | DELINEATION OF CLINICAL PRIVILEGES - AEROSPACE MEDICINE | $4.99 |
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| DA 5440-25 | DELINEATION OF CLINICAL PRIVILEGES - GENERAL MEDICAL OFFICER | $4.99 |
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| DA 5440-28 | DELINEATION OF CLINICAL PRIVILEGES | $4.99 |
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| DA 5440-29 | DELINEATION OF CLINICAL PRIVILEGES - ALLERGY/IMMUNOLOGY | $4.99 |
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| DA 5440-3 | DELINEATION OF CLINICAL PRIVILEGES - INTERNAL MEDICINE | $4.99 |
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| DA 5440-30 | DELINEATION OF CLINICAL PRIVILEGES - NEPHROLOGY | $4.99 |
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| DA 5440-31 | DELINEATION OF CLINICAL PRIVILEGES - CHIROPRACTIC | $4.99 |
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| DA 5440-32 | DELINEATION OF CLINICAL PRIVILEGES - DERMATOLOGY | $4.99 |
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| DA 5440-33 | DELINEATION OF CLINICAL PRIVILEGES - UROLOGY | $4.99 |
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| DA 5440-34 | DELINEATION OF CLINICAL PRIVILEGES - BEHAVIORAL HEALTH PRACTIONER | $4.99 |
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| DA 5440-35 | DELINEATION OF CLINICAL PRIVILEGES - PSYCHOLOGICAL ASSOCIATE | $4.99 |
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| DA 5440-36 | DELINEATION OF CLINICAL PRIVILEGES - AUDIOLOGY | $4.99 |
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| DA 5440-37 | DELINEATION OF CLINICAL PRIVILEGES - SPEECH PATHOLOGY | $4.99 |
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| DA 5440-38 | DELINEATION OF CLINICAL PRIVILEGES - CLINICAL PHARMACY | $4.99 |
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| DA 5440-39 | DELINEATION OF CLINICAL PRIVILEGES - NUCLEAR MEDICINE | $4.99 |
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| DA 5440-4 | DELINEATION OF CLINICAL PRIVILEGES - NEUROLOGY | $4.99 |
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| DA 5440-40 | DELINEATION OF CLINICAL PRIVILEGES - THERAPEUTIC RADIOLOGY | $4.99 |
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| DA 5440-41 | DELINEATION OF CLINICAL PRIVILEGES - PHYSICAL MEDICINE AND REHABILITATION | $4.99 |
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| DA 5440-42 | DELINEATION OF CLINICAL PRIVILEGES - CARDIOLOGY | $4.99 |
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| DA 5440-43 | DELINEATION OF CLINICAL PRIVILEGES - OPHTHAMOLOGY | $4.99 |
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| DA 5440-44 | DELINEATION OF CLINICAL PRIVILEGES - OTOLARYNGOLOGY | $4.99 |
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| DA 5440-45 | DELINEATION OF CLINICAL PRIVILEGES - CARDIOVASCULAR SURGERY | $4.99 |
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| DA 5440-46 | DELINEATION OF CLINICAL PRIVILEGES - PULMONARY DISEASE | $4.99 |
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| DA 5440-47 | DELINEATION OF CLINICAL PRIVILEGES - PREVENTIVE MEDICINE | $4.99 |
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| DA 5440-48 | DELINEATION OF CLINICAL PRIVILEGES - ORAL & MAXILLOFACIAL SURGERY | $4.99 |
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| DA 5440-49 | DELINEATION OF CLINICAL PRIVILEGES - PLASTIC SURGERY | $4.99 |
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| DA 5440-5 | DELINEATION OF CLINICAL PRIVILEGES - OBSTETRICS AND GYNECOLOGY | $4.99 |
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| DA 5440-50 | DELINEATION OF CLINICAL PRIVILEGES - VASCULAR SURGERY | $4.99 |
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| DA 5440-51 | DELINEATION OF CLINICAL PRIVILEGES - NEUROSURGERY | $4.99 |
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| DA 5440-52 | DELINEATION OF CLINICAL PRIVILEGES - CRITICAL CARE MEDICINE | $4.99 |
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| DA 5440-53 | DELINEATION OF CLINICAL PRIVILEGES - OCCUPATIONAL MEDICINE | $4.99 |
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| DA 5440-54 | DELINEATION OF CLINICAL PRIVILEGES - THORACIC SURGERY | $4.99 |
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| DA 5440-55 | DELINEATION OF CLINICAL PRIVILEGES - ORTHOPAEDICS | $4.99 |
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| DA 5440-56 | DELINEATION OF CLINICAL PRIVILEGES - BLOOD SERVICES | $4.99 |
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| DA 5440-57 | DELINEATION OF CLINICAL PRIVILEGES - PSYCHIATRIC ADVANCED PRACTICE NURSE | $4.99 |
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| DA 5440-58 | DELINEATION OF CLINICAL PRIVILEGES - SUBSTANCE ABUSE REHABILITATION | $4.99 |
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| DA 5440-6 | DELINEATION OF CLINICAL PRIVILEGES - OPTOMETRY | $4.99 |
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| DA 5440-7 | DELINEATION OF CLINICAL PRIVILEGES - PATHOLOGY | $4.99 |
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| DA 5440-8 | DELINEATION OF CLINICAL PRIVILEGES - PEDIATRICS | $4.99 |
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| DA 5440-9 | DELINEATION OF CLINICAL PRIVILEGES - PODIATRY | $4.99 |
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| DA 5440A | APPROVAL OF CLINICAL PRIVILEGES/STAFF APPOINTMENT | $4.99 |
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| DA 5441 | EVALUATION OF CLINICAL PRIVILEGES - ANESTHESIA | $4.99 |
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| DA 5441-1 | EVALUATION OF CLINICAL PRIVILEGES - DENTISTRY | $4.99 |
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| DA 5441-11 | EVALUATION OF CLINICAL PRIVILEGES - CLINICAL PSYCHOLOGY | $4.99 |
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| DA 5441-12 | EVALUATION OF CLINICAL PRIVILEGES - DIAGNOSTIC RADIOLOGY | $4.99 |
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| DA 5441-13 | EVALUATION OF CLINICAL PRIVILEGES - GENERAL SURGERY | $4.99 |
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| DA 5441-14 | EVALUATION OF CLINICAL PRIVILEGES - NURSE ANESTHETIST | $4.99 |
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| DA 5441-15 | EVALUATION OF CLINICAL PRIVILEGES - CERTIFIED NURSE MIDWIFE | $4.99 |
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| DA 5441-16 | EVALUATION OF CLINICAL PRIVILEGES - NURSE PRACTITIONER | $4.99 |
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| DA 5441-18 | EVALUATION OF CLINICAL PRIVILEGES - PHYSICIAN ASSISTANT | $4.99 |
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| DA 5441-19 | EVALUATION OF CLINICAL PRIVILEGES - DIETETICS | $4.99 |
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| DA 5441-2 | EVALUATION OF CLINICAL PRIVILEGES - FAMILY PRACTICE | $4.99 |
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| DA 5441-20 | EVALUATION OF CLINICAL PRIVILEGES - OCCUPATIONAL THERAPY | $4.99 |
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| DA 5441-21 | EVALUATION OF CLINICAL PRIVILEGES - PHYSICAL THERAPY | $4.99 |
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| DA 5441-22 | EVALUATION OF CLINICAL PRIVILEGES | $4.99 |
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| DA 5441-23 | EVALUATION OF CLINICAL PRIVILEGES - EMERGENCY MEDICINE | $4.99 |
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| DA 5441-24 | EVALUATION OF CLINICAL PRIVILEGES - AEROSPACE MEDICINE | $4.99 |
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| DA 5441-25 | EVALUATION OF CLINICAL PRIVILEGES - GENERAL MEDICAL OFFICER | $4.99 |
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| DA 5441-28 | EVALUATION OF CLINICAL PRIVILEGES - SOCIAL WORK | $4.99 |
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| DA 5441-29 | EVALUATION OF CLINICAL PRIVILEGES - ALLERGY/IMMUNOLOGY | $4.99 |
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| DA 5441-3 | EVALUATION OF CLINICAL PRIVILEGES - INTERNAL MEDICINE | $4.99 |
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| DA 5441-30 | EVALUATION OF CLINICAL PRIVILEGES - NEPHROLOGY | $4.99 |
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| DA 5441-31 | EVALUATION OF CLINICAL PRIVILEGES - CHIROPRACTIC | $4.99 |
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| DA 5441-32 | EVALUATION OF CLINICAL PRIVILEGES - DERMATOLOGY | $4.99 |
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| DA 5441-33 | EVALUATION OF CLINICAL PRIVILEGES - UROLOGY | $4.99 |
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| DA 5441-34 | EVALUATION OF CLINICAL PRIVILEGES - BEHAVIORAL HEALTH PRACTITIONER | $4.99 |
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| DA 5441-35 | EVALUATION OF CLINICAL PRIVILEGES - PSYCHOLOGICAL ASSOCIATE | $4.99 |
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| DA 5441-36 | EVALUATION OF CLINICAL PRIVILEGES - AUDIOLOGY | $4.99 |
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| DA 5441-37 | EVALUATION OF CLINICAL PRIVILEGES - SPEECH PATHOLOGY | $4.99 |
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| DA 5441-38 | EVALUATION OF CLINICAL PRIVILEGES - CLINICAL PHARMACY | $4.99 |
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| DA 5441-39 | EVALUATION OF CLINICAL PRIVILEGES - NUCLEAR MEDICINE | $4.99 |