Forms


Reporting Forms

F09-11709: Child Blood Lead Reporting Form  - Revised 04/20/2017
Used by healthcare providers to report blood lead level(s) for children under 15 years of age.

F09-11624: Adult Blood Lead Reporting Form
Used by healthcare providers to report blood lead level(s) for children/adults 15 years of age and older.

Pb-111: Point-Of-Care Blood Lead Testing Report - Revised 02/25/2016
Used by healthcare providers to report blood lead levels when using an point-of-care blood lead analyzer.

 

Environmental Lead Investigation forms 

Pb-101: Request for Environmental Investigation - Revised 09/08/15
Used by healthcare providers to request and Environmental Lead Investigation for a child with a venous blood lead level test result of 20 µg/dL and higher, or two separate venous BLL tests collected at least 12 weeks apart in the 10-19 µg/dL range.

Pb-103: Elevated Blood Lead Level Investigation Questionnaire - Revised 06/09/2017
Used by Lead Risk Assessors to conduct Environmental Lead Investigations.

 

Follow-up and physician resources 

Pb-102: Follow-up of Initial Elevated Blood Lead Level- Revised 10/16/17
Used by healthcare providers for follow-up of elevated blood lead levels of a child.

Pb-104: Physician Checklist for Parent Education Topics - Revised 06/15/2015
Used by healthcare providers to determine the appropriate lead educational material to provide parents for medical care, environmental intervention, and nutritional intervention.

Pb-109: Reference for Blood Lead Retesting and Medical Case Management - Revised 01/29/2015 
Used by healthcare providers to determine when follow-up blood lead testing is necessary. Specifically: “Schedule for Obtaining a Diagnostic Venous sample”, “Schedule for Follow-up Venous Blood Lead Testing After Diagnostic Venous Sample”, and “Recommendations for Children with Diagnostic Elevated Blood Lead Levels”.

Pb-110: Lead Risk Questionnaire (English Version) - Revised 12/22/2011
Pb-110: Lead Risk Questionnaire (Spanish Version) - Revised 11/18/11
The lead risk questionnaire is located on page 2 of the "Texas Childhood Blood Lead Screening Guidelines: Quick Reference Guide."

Last updated January 17, 2018