Hansen's Disease - Forms
Standard of Care
| Form Number | Title | Revision Date |
|---|---|---|
| - | Hansen’s Disease Service Delivery Work Plan | 12/2024 |
Reporting
| Form Number | Title | Revision Date |
|---|---|---|
| C-12 | Texas Hansen’s Disease Surveillance Form with NHDP Surveillance and Case Report (DSHS Clinic Form) | 1/2024 |
Clinical Care
| Form Number | Title | Revision Date |
|---|---|---|
| HD-400 | Texas Hansen’s Disease Encounter Form | 1/2024 |
| HD-406 | Change of Patient Information | 9/2020 |
| NHDP-130 | Hand Evaluation Screen | 8/2020 |
| NHDP-133 | Foot Evaluation Screen | 10/2017 |
| NHDP-216 | Eye Evaluation Screen | 1/2017 |
| NHDP-208 | NHDP Annual Follow Up Form | 9/2020 |
Biopsy and Skin Smears
| Form Number | Title | Revision Date |
|---|---|---|
| HD-408 | Skin Smear and Biopsy Chart | 4/2018 |
| NHDP-199 | Pathology Consult Request Form | 8/2020 |
| Procedure for Skin Smears | 10/2008 |
Consent
| Form Number | Title | Revision Date |
|---|---|---|
| HD-405 | Patient Agreement for Hansen’s Disease (English) | 10/2017 |
| HD-405a | Patient Agreement for Hansen’s Disease (Spanish) | 10/2017 |
| HD-414 | Photo Consent (English) | 2/2024 |
| HD-414a | Photo Consent (Spanish) | 2/2024 |
| CD-001 | Disclosure and Consent Drug Therapy for Treatment of Hansen’s Disease (English) | 2/2024 |
| CD-001a | Disclosure and Consent Drug Therapy for Treatment of Hansen’s Disease (Spanish) | 2/2024 |
| CD-010 | Disclosure and Consent Skin Biopsy for Hansen’s Disease or Case Suspects (English and Spanish) | 12/2017 |
| CD-011 | Disclosure and Consent Skin Scraping for Hansen’s Disease and Case Suspects (English and Spanish) | 12/2017 |
| L-30 | Consent to Release Confidential Medical Information (English) | 7/2016 |
| L-30a | Consent to Release Confidential Medical Information (Spanish) | 7/2016 |
| L-36/L-36a | General Consent and Disclosure (English/Spanish) | 4/2010 |
General Clinic Information
| Form Number | Title | Revision Date |
|---|---|---|
| HD-407 | DSHS Change in Personnel Form | 6/2020 |
| HD-409 | Patient Statuses | 4/2020 |
| HD-410 | Hansen’s Disease Clinic Quality Assurance Reporting Form | 12/2023 |
| HD-411 | Reporting and Clinical Care Forms Deadlines | 2/2024 |
| HD-412 | Hansen’s Disease Medication Formulary | 2/2024 |
| HD-413 | Order Non-formulary Hansen’s Disease Medications | 6/2020 |
| Comprehensive List of Authorized Services | 4/2018 |