Forms

Hansen's Disease Program

(Mycobacterium leprae, Leprosy) ICD-9 030; ICD-10 A30

Hansen's Disease Forms

Reporting

Form Number	Title	Format/Size	Revision Date
C-12	Texas Hansen’s Disease Surveillance Form with NHDP Surveillance and Case Report (DSHS Clinic Form)	PDF 852 kB	9/2020

Clinical Care

Form Number	Title	Format/Size	Revision Date
HD-400	Texas Hansen’s Disease Encounter Form	PDF 654 kB	6/2020
HD-406	Change of Patient Information	PDF 89 kB	9/2020
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 153 kB	9/2020

Biopsy and Skin Smears

Form Number	Title	Format/Size	Revision Date
HD-408	Skin Smear and Biopsy Chart	PDF 102 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/Size	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	7/2016
L-30a	Consent to Release Confidential Medical Information (Spanish)	PDF 196 kB	7/2016
L-36/L-36a	General Consent and Disclosure (English/Spanish)	PDF 26 kB	4/2010

General Clinic Information

Form Number	Title	Format/Size	Revision Date
HD-407	DSHS Change in Personnel Form	PDF 191 kB	6/2020
HD-409	Patient Statuses	PDF 130 kB	4/2020
HD-410	Quality Improvement Activity Report	PDF 105 kB	4/2020
HD-411	Reporting and Clinical Care Forms Deadlines	PDF 310 kB	7/2020
HD-412	Hansen’s Disease Medication Formulary	PDF 159 kB	6/2020
HD-413	Order Non-formulary Hansen’s Disease Medications	PDF 90 kB	6/2020
	Comprehensive List of Authorized Services	PDF 49 kB	4/2018

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