Reporting
Forms
F09-11709: Child Blood Lead Reporting
Form - Revised August 2018
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 August 2018
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 August 2018
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 August 2018
Used by healthcare
providers for follow-up of elevated blood lead levels of a child.
Pb-104: Physician Checklist for
Parent Education Topics - Revised August 2018
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 August 2018
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 August 2018
Pb-110: Lead Risk Questionnaire
(Spanish Version) - Revised June 2020
The lead risk
questionnaire is located on page 8 of the "2019 Childhood Blood Lead
Screening Guidelines"