Forms

Blood Lead Surveillance Branch

Blood Lead Surveillance Branch

Blood Lead Information For Providers

Forms

Reporting Forms

Electronic Reporting Form

Used by healthcare providers to submit blood lead test results by electronic submission

Child Blood Lead Reporting Form (F09-11709)  - Revised January 2021
Used by healthcare providers to report blood lead level(s) for children under 15years of age.

Adult Blood Lead Reporting Form (F09-11624) - Revised January 2012
Used by healthcare providers to report blood lead level(s) for children/adults 15 years of age and older.

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

Screening & Testing

2019 Texas Childhood Blood Lead Screening Guidelines (Pb-120) -  Revised June 2020
Targeted zip codes have one or more associated census tract in which:

Lead Risk Questionnaire (Pb-110) (English Version) - Revised August 2018

The lead risk questionnaire is also included in the "2019 Texas Childhood Blood Lead Screening Guidelines" document, on page 8.

Follow-Up

Follow-up of Initial Elevated Blood Lead Level (Pb-102) - Revised January 2023
Used by healthcare providers for follow-up of elevated blood lead levels of a child.

Physician Checklist for Parent Education Topics (Pb-104) - Revised April 2023
Used by healthcare providers to determine the appropriate lead educational material to provide parents for medical care, environmental intervention, and nutritional intervention.

Reference for Blood Lead Retesting and Medical Case Management (Pb-109) - Revised March 2024
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”.

Environmental Lead Investigation forms 

Pb-101: Request for Environmental Investigation (Pb-101) - 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 the10-19 µg/dL range.

Pb-103: Elevated Blood Lead Level Investigation Questionnaire (Pb-103) - Revised August 2019
Used by Lead Risk Assessors to conduct Environmental Lead Investigations.