Hansen's Disease - Forms

Standard of Care

Form NumberTitleRevision Date
-Hansen’s Disease Service Delivery Work Plan12/2024

 

Reporting

Form NumberTitleRevision Date
C-12Texas Hansen’s Disease Surveillance Form with NHDP Surveillance and Case Report (DSHS Clinic Form)2/2025

 

Clinical Care

Form NumberTitleRevision Date
HD-400Texas Hansen’s Disease Encounter Form2/2025
HD-406 Change of Patient Information9/2020
NHDP-130Hand Evaluation Screen8/2020 
NHDP-133Foot Evaluation Screen10/2017
NHDP-216 Eye Evaluation Screen1/2017
NHDP-208NHDP Annual Follow Up Form2/2025

 

Biopsy and Skin Smears

Form NumberTitleRevision Date
HD-408Skin Smear and Biopsy Chart4/2018
NHDP-199Pathology Consult Request Form8/2020
 Procedure for Skin Smears10/2008

 

Consent

Form NumberTitleRevision Date
HD-405Patient Agreement for Hansen’s Disease (English)10/2017
HD-405aPatient Agreement for Hansen’s Disease (Spanish)10/2017 
HD-414Photo Consent (English)2/2024
HD-414aPhoto Consent (Spanish)2/2024
CD-001Disclosure and Consent Drug Therapy for Treatment of Hansen’s Disease (English)2/2024
CD-001aDisclosure and Consent Drug Therapy for Treatment of Hansen’s Disease (Spanish)2/2024
CD-010Disclosure and Consent Skin Biopsy for Hansen’s Disease or Case Suspects (English and Spanish)12/2017
CD-011Disclosure and Consent Skin Scraping for Hansen’s Disease and Case Suspects (English and Spanish)12/2017
L-30Consent to Release Confidential Medical Information (English)7/2016 
L-30aConsent to Release Confidential Medical Information (Spanish)7/2016 
L-36/L-36aGeneral Consent and Disclosure (English/Spanish)4/2010 

 

General Clinic Information

Form NumberTitleRevision Date
HD-407DSHS Change in Personnel Form6/2020
HD-409Patient Statuses4/2020
HD-410  Hansen’s Disease Clinic Quality Assurance Reporting Form6/2025
HD-411 Reporting and Clinical Care Forms Deadlines2/2024
HD-412Hansen’s Disease Medication Formulary2/2024
HD-413 Order Non-formulary Hansen’s Disease Medications6/2020 
 Comprehensive List of Authorized Services4/2018