CDC's Bacterial Special Pathogens Branch uses this form for national surveillance of Hansen's disease (leprosy). A clinician meets it after diagnosing or treating a case, usually when the state health department gathers the clinical details. It covers exposure history such as armadillo contact and every place the patient has lived, leprosy type, biopsy and skin smear results, treatment, disabilities and household contacts.
The diagnosing or treating clinician, or the state health department reporter, completes the whole form, with the reporter's contact details in the reporting information block. The first two pages explain each variable.
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Hansen's Disease Case Report Form
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No. CDC asks that the form be sent with all personal identifiers removed. The state's own local record ID links the report back to the patient, and the comments field should not contain identifying details. The reporter's name, phone number and email are included as the contact for the case.
Whether the patient ever had direct contact with armadillos, was ever treated for latent or active tuberculosis, was previously diagnosed or treated for Hansen's disease, or received post-exposure prophylaxis, including PEP given outside the US. It also asks for every place the patient lived before diagnosis and the patient's country of birth.
Lepromatous (LL), borderline lepromatous (BL), dimorphous or borderline (BB), borderline tuberculoid (BT), tuberculoid (TT), indeterminate or other. The form also records biopsy results and skin smear grading from 1+ to 6+ or none found, with the date and the country or state of initial diagnosis.