Form Dhndp - Hansen'S Disease (Leprosy) Surveillance Form printable pdf download

Instructions for Completing the

Hansen’s Disease (Leprosy) Surveillance Form

The H ansen’s D isease or Leprosy Surveillance F orm (LSF) is t he document u sed t o r eport leprosy c ases t o t he U.S.

National Hansen’s Disease Registry. These data are used for epidemiological, clinical, and basic research studies

throughout the National Hansen’s Disease Program (NHDP), and are the official source for information on leprosy cases in

the U.S.

The information requested on the LSF is used by many clinicians and researchers, and collection of all information is highly

desirable. H owever, t he f ields t hat ar e boldfaced on t he f orm and i n t he instructions be low are c onsidered t o be t he

minimal i nformation needed t o register a patient. Failure to provide t his i nformation will r esult in t he f orm being r eturned

which creates additional work and may cause delays in obtaining program services for the patient.

Reporting State: Use the abbreviation of the state from which the report is being sent. This is usually the state of

the clinician’s office and not necessarily the patient’s resident state.

Date o f R eport: This i s date of the initial L SF c ompletion. I f pat ient was pr eviously r eported an d has r elapsed,

write the word “RELAPSE” next to the date.

Social Security Number: self-explanatory.

Patient Name: Self-explanatory.

Present Address: Please include the county and zip code which are used to geographically cluster patients.

Place of Birth: Include state and county, if born in the U.S., or the country, if foreign born.

Date of Birth/Sex: Self-explanatory.

Race/Ethnicity: This information should be voluntarily provided by the patient. If the patient refuses or indicates a

race/ethnicity category not listed, check the “Not Specified” box.

Date Entered the U.S.: For patients who have immigrated to the U.S., provide the month and year of entry.

10.

Date of Onset of Symptoms: This information is usually the patient’s recollection of when classic leprosy symptoms

(rash, nodule formation, paresthesia, decreased peripheral sensation, etc.) were first noticed.

11.

Date Leprosy First Diagnosed: Provide the month and year a diagnosis was made. This usually coincides with a

biopsy date if one was performed.

12.

Initial Diagnosis: Was the patient diagnosed in the U.S. or outside the U.S.

13.

Type of Leprosy: Classify the diagnosis based on one of the ICD-9-CM diagnosis codes.

030.0 Lepromatous Leprosy (macular, diffuse, infiltrated, nodular, neuritic – includes Ridley-Jopling [RJ],

Lepromatous [LL] and Borderline lepromatous [BL]): A form marked by erythematous macules, generalized

papular and nodular lesions, and variously by upper respiratory infiltration, nodules on conjunctiva or sclera, and

motor loss.

030.1 T uberculoid L eprosy (macular, maculoanesthetic, major, minor, neuritic – includes RJTuberculoid

[TT] and Borderline tuberculoid [BT]): A form marked by usually one lesion with well-defined margins with scaly

surface and local tender cutaneous or peripheral nerves.

030.2 I ndeterminate (uncharacteristic, macular, neuritic): A f orm marked by one or m ore macular l esions,

which may have slight erythema.

030.3 Borderline (dimorphous, infiltrated, neuritic – includes RJ Borderline [BB] or true mid disease only):

A form marked by early nerve involvement and lesions of varying stages.

030.8 O ther S pecified L eprosy: Use t his c ode when t he di agnosis i s s pecified as a “ leprosy” bu t i s not l isted

above (030.0-030.3).

030.9 Leprosy, Inactive: Use this code when the diagnosis is identified as a “leprosy” but inactive.

14.

Diagnosis of Disease: Enter INITIAL biopsy and skin smear dates and results.

15.

Residence (Pre-diagnosis): List a ll c ities, c ounties, and s tates i n t he U .S. a nd a ll f oreign c ountries a pat ient

resided in BEFORE leprosy was diagnosed. This information is used to map all places where U.S. leprosy cases

have resided.

16.

Disability: Indicate any sensory abnormalities or deformities of the hands and feet or lagophthalmos of the eyes.

17.

Current Household Contacts: Self-explanatory.

18.

Current Treatment for Leprosy: Date treatment started and indicate all drugs used for initial treatment.

19.

Name and Address of Physician or Investigator: Self-explanatory.

Form Dhndp - Hansen'S Disease (Leprosy) Surveillance Form

Related Articles

Related forms

Related Categories