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    TB and Hansen's Disease Branch

    MC 1939
    P.O. Box 149347
    Austin, TX 78756-9347

    Phone:
    Fax: 512-533-3167


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Forms

 

Hansen's Disease Program
Hansen (Mycobacterium leprae, Leprosy)
ICD-9 030; ICD-10 A30

Hansen's Disease Forms

Reporting

Form Number Title Format(s) Revision Date
C-12 Texas Hansen’s Disease Surveillance Form with NHDP Surveillance and Case Report (DSHS Clinic Form)
PDF 708 kB 4/2018


Clinical Care

Form Number Title Format(s) Revision Date
HD-400
Texas Hansen’s Disease Encounter Form
PDF 572 kB 06/2018
HD-406  Change of Patient Information PDF 176 kB 4/2018
NHDP-130 Hand Evaluation Screen PDF 191 kB  10/2017 
NHDP-133 Foot Evaluation Screen PDF 169 kB 10/2017
NHDP-216  Eye Evaluation Screen PDF 7,678 kB 1/2017
NHDP-208 NHDP Annual Follow Up Form PDF 108 kB 3/2016


Biopsy and Skin Smears

Form Number Title Format(s) Revision Date
HD-408 Skin Smear and Biopsy Chart PDF 98 kB 4/2018
NHDP-199
Pathology Consult Request Form
PDF 328 kB 10/2019
   Procedure for Skin Smears PDF 224 kB 10/2008


Consent

Form Number Title Format(s) Revision Date
HD-405 
Patient Agreement for Hansen’s Disease (English)
PDF 142 kB 10/2017
HD-405a
Patient Agreement for Hansen’s Disease (Spanish)
PDF 142 kB 10/2017 
CD-001
Disclosure and Consent Drug Therapy for Treatment of Hansen’s Disease (English)
PDF 125 kB 12/2017
CD-001a
Disclosure and Consent Drug Therapy for Treatment of Hansen’s Disease (Spanish) PDF 135 kB  12/2017
CD-010 Disclosure and Consent Skin Biopsy for Hansen’s Disease or Case Suspects (English and Spanish) PDF 191 kB 12/2017
CD-011 Disclosure and Consent Skin Scraping for Hansen’s Disease and Case Suspects (English and Spanish) PDF 174 kB 12/2017
L-30 Consent to Release Confidential Medical Information (English) PDF 182 kB 07/2016 
L-30a
Consent to Release Confidential Medical Information (Spanish) PDF 196 kB 07/2016 
L-36/L-36a General Consent and Disclosure (English/Spanish) PDF 26 kB 04/2010 
       


General Clinic Information

Form Number Title Format(s) Revision Date
HD-407 DSHS Change in Personnel Form PDF 167 kB 4/2018
HD-409 Patient Statuses PDF 48 kB 9/2018
HD-410   Quality Improvement Activity Report PDF 977 kB 6/2019 
HD-411  Reporting and Clinical Care Forms Deadlines PDF 43 kB  9/2018
HD-412 Hansen’s Disease Medication Formulary PDF 43 kB 5/2018
HD-413  Order Non-formulary Hansen’s Disease Medications  PDF  31 kB 5/2018 
   Comprehensive List of Authorized Services PDF 45 kB 4/2018



 

Last updated October 18, 2019