Childhood Lead Risk Questionnaire

STATE LAW REQUIRES:
All children 6 years of age or younger must be evaluated for lead exposure.
All children must be assessed for risk of lead exposure and tested if necessary for enrollment into daycare, preschool, and kindergarten.

Complete the Childhood Lead Risk Questionnaire during a well-child or health care visit for children ages 12 and 24 months of age (at minimum) and once a year at annual well-child-visits at ages 3, 4, 5, and 6 years.

If responses to all the questions are "NO," re-evaluate at the next age referenced above or more often if deemed necessary.
If any response is "'YES" or "DON'T KNOW," a blood lead test must be obtained.
If there are any "YES" or "DON" T KNOW" answers and
Previous blood lead testing was done at 12 and 24 months of age with a result of 4.9 ug/dL or less OR if not performed at 12 and 24 months, a blood lead test was performed at 3, 4, 5, or 6 years of age with a result of 4.9 ug/dL or less, and
There has been no change in address of the child's home/residential building, child care facility, school, or other frequently visited facilities and
Risks of exposure to lead have not changed, further blood lead tests are not necessary,

Child's Name

Date

Age

Birthdate

Zip Code

1. Does this child reside or regularly visit a home/residential building, child-care setting, school or other facility built before 1978 or in a high risk ZIP code area? (see reverse side of page for high risk ZIP code area list)

Yes No Don't Know

2. is this child eligible for or enrolled in Medicaid, Ail Kids, Head Start, WIC, or any HFS medical program?

Yes No Don't Know

All Medicaid-eligible children and children enrolled in HFS medical programs shall have a blood lead test at 12 and at 24 months of age. If a Medicaid-eligible child or HFS medical program enrolled child between 36 months and 72 months of age has not been previously tested, a blood lead test shall be performed.

3. Does this child have a sibling with a confirmed blood lead level of 5 vg/dL or higher?

Yes No Don't Know

4. In the past year, has this child been exposed to repairs, repainting, or renovation of a building/home built before 1978?

Yes No Don't Know

5. Is this child a refugee, adoptee, or recent visitor of any foreign country?

Yes No Don't Know

6. Is this child frequently exposed to imported items (such as, ayurvedic medicine, folk medicines, cosmetics, toys, glazed pottery, spices or other food items, sindoor, or kumkum)?

Yes No Don't Know

7. Does this child live with someone who has a job or a hobby that may involve lead (for example; jewelry making, building renovation, bridge construction, plumbing, furniture refinishing, work with automobile batteries or radiators, lead solder, leaded glass, bullets, lead fishing sinkers, or recycling facility work)?

Yes No Don't Know

8. If the child is younger than 12 months of age. did the child's mother have a past confirmed blood lead level of 5 ug/dL or higher?

Yes No Don't Know

9. Has the water in your home/residential building. child-care setting, school, or other regularly visited facility been tested and had a confirmed level of lead (5 ppb or higher)?

Yes No Don't Know

10. Does your child live near an active lead smelter, battery recycling plant, or another industry likely to release lead, or does your child live near a heavily-traveled road where soil and dust may be contaminated with lead?

Yes No Don't Know

ALL blood lead test results MUST be submitted to the Illinois Lead Program.
Fax: 217-557-1188 Phone: 866-909-3572

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of doctor / Nurse

Date

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Childhood Lead Risk Questionnaire

STATE LAW REQUIRES:All children 6 years of age or younger must be evaluated for lead exposure.All children must be assessed for risk of lead exposure and tested if necessary for enrollment into daycare, preschool, and kindergarten.

STATE LAW REQUIRES:
All children 6 years of age or younger must be evaluated for lead exposure.
All children must be assessed for risk of lead exposure and tested if necessary for enrollment into daycare, preschool, and kindergarten.