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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 Revision Date
C-12 Texas Hansen’s Disease Surveillance Form with NHDP Surveillance and Case Report (DSHS Clinic Form) (PDF)
9/2020


Clinical Care

Form Number Title Revision Date
HD-400 Texas Hansen’s Disease Encounter Form (PDF) 6/2020
HD-406  Change of Patient Information (PDF) 9/2020
NHDP-130 Hand Evaluation Screen (PDF) 8/2020 
NHDP-133 Foot Evaluation Screen (PDF) 10/2017
NHDP-216  Eye Evaluation Screen (PDF) 1/2017
NHDP-208 NHDP Annual Follow Up Form (PDF) 9/2020


Biopsy and Skin Smears

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


Consent

Form Number Title Revision Date
HD-405 
Patient Agreement for Hansen’s Disease (English) (PDF)
10/2017
HD-405a
Patient Agreement for Hansen’s Disease (Spanish) (PDF)
10/2017 
CD-001
Disclosure and Consent Drug Therapy for Treatment of Hansen’s Disease (English) (PDF)
12/2017
CD-001a
Disclosure and Consent Drug Therapy for Treatment of Hansen’s Disease (Spanish) (PDF) 12/2017
CD-010 Disclosure and Consent Skin Biopsy for Hansen’s Disease or Case Suspects (English and Spanish) (PDF) 12/2017
CD-011 Disclosure and Consent Skin Scraping for Hansen’s Disease and Case Suspects (English and Spanish) (PDF) 12/2017
L-30 Consent to Release Confidential Medical Information (English) (PDF) 7/2016 
L-30a
Consent to Release Confidential Medical Information (Spanish) (PDF) 7/2016 
L-36/L-36a General Consent and Disclosure (English/Spanish) (PDF) 4/2010 


General Clinic Information

Form Number Title Revision Date
HD-407 DSHS Change in Personnel Form (PDF) 6/2020
HD-409 Patient Statuses (PDF) 4/2020
HD-410   Quality Improvement Activity Report (PDF) 4/2020 
HD-411  Reporting and Clinical Care Forms Deadlines (PDF) 7/2020
HD-412 Hansen’s Disease Medication Formulary (PDF) 6/2020
HD-413  Order Non-formulary Hansen’s Disease Medications (PDF) 6/2020 
   Comprehensive List of Authorized Services (PDF) 4/2018



Last updated May 25, 2021