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F09-11709: Child Blood Lead Reporting Form
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-100: Possible Sources of Lead Exposure: Interview Questions - Revised 01/04/12
Used by healthcare providers to interview the parent/guardian of a child with a diagnostic elevated blood lead level to determine possible source(s) of lead exposure.
Pb-101: Request for Environmental Investigation - Revised 05/28/14
Used by healthcare providers to request and Environmental Lead Investigation for a child with a venous blood lead level test result of 20 mcg/dL and higher, or two separate venous BLL tests collected at least 12 weeks apart in the 10-19 mcg/dL range.
Pb-102: Follow-up of an Elevated Blood Lead Level- Revised 01/04/12
Used by healthcare providers for follow-up of elevated blood lead levels of a child.
Pb-103: Elevated Blood Lead Level Investigation Questionnaire - Revised 04/26/11
Used by Lead Risk Assessors to conduct Environmental Lead Investigations.
Pb-104: Physician Checklist for Parent Education Topics
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 Follow-up Blood Lead Testing and Medical Case Management - Effective 05/01/2013
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."
Pb-111: Point-Of-Care Blood Lead Testing Report - Created 04/26/12
Used by healthcare providers to report blood lead levels when using an point-of-care blood lead analyzer.
Point-Of-Care Blood Lead Testing Report - Excel Spreadsheet
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Healthcare Provider Forms

Last updated August 05, 2014