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Hansen's Disease - Forms

Standard of Care

Form Number Title Revision Date
- Hansen’s Disease Service Delivery Work Plan 1/2024

 

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