Section 840.APPENDIX C Forms and Instructions for Occupational Disease Registry

Section 840.EXHIBIT A Instructions for completing The Laboratory Based Report of Adult Blood Lead Analysis

The Adult Elevated Blood Lead Analysis form should be completed for all blood lead test with concentrations 25 mcg/dl or greater on all persons 16 years of age and older. All laboratories in Illinois certified by the Illinois Department of Public Health and Occupational Safety and Health Administration (OSHA) to conduct a blood lead analysis are required to complete the Adult Elevated Blood Lead Analysis form.

1. THE ILLINOIS DEPARTMENT OF PUBLIC HEALTH CASE NUMBER: The case number will be completed by the Illinois Department of Public Health.

2. DATE OR REPORT: Enter the month, day and year the form is being completed. Use two digits, e.g., 08/03 for month and date. For example, use four digits for year 1989.

CASE DATA

3. Complete the following information on the case's complete name (if unknown enter slashes in the space provided):

• LAST NAME: Enter the case's complete last name.

• FIRST NAME: Enter the case's complete first name.

• MIDDLE INITIAL: Enter the case's middle initial.

• MAIDEN NAME: If applicable, enter the case's complete maiden name.

ADDRESS OF CASE: If information is available, complete the following elements on the form. Slashes should be entered in the space provided if unknown. All elements refer to domicile, i.e., the address from which the case may lawfully register to vote if proper age is attained.

• NUMBER: Enter the number of case's current street address.

• DIRECTION: Enter the direction which appears in the case's current street address, e.g. North, West.

• STREET NAME: Enter the name of the case's current street address.

• APARTMENT NUMBER: If applicable, enter the apartment number of the case's domiciled address.

• TYPE: Enter the applicable type of street address, e.g. avenue, street, boulevard.

• CITY: Enter the complete name of the city in which the case currently is domiciled.

• STATE: Enter the state where the case currently is domiciled. Use the standard two digit abbreviations.

• ZIP CODE: Enter the five digit zip code where the case currently is domiciled.

4. COUNTY: Enter the complete name of the county where the case currently is domiciled.

CODE: The Illinois Department of Public Health will complete the code.

5. TELEPHONE NUMBER: If available, enter the case's telephone number (area code and seven digit number). If unknown, enter slashes in boxes provided.

6. DATE OF BIRTH: If available, enter the data of birth for the case. Use two digits for the month and the date. Use four digits for the year. If unknown, enter slashes in boxes provided.

7. SEX: If available, enter the appropriate number for the sex of case in the box provided. Record 1 for a male, 2 for a female, 3 for other (includes hermaphrodites and instances of definitive sex change) and a 9 for unknown.

SUBMITTING PARTY DATA

8. NAME: Enter the name of the person, industry, physician, hospital, laboratory, clinic or other submitting the elevated blood lead sample to the laboratory to be analyzed.

TITLE: Enter the title if applicable of person submitting the elevated blood lead sample to the laboratory to be analyzed.

9. TELEPHONE NUMBER: Enter the telephone number of the submitting party (area code and seven digit number).

10. TYPE: Enter the type of party submitting the sample in the box provided. If a physician submits the elevated blood lead sample indicate by marking 1 in box. For industry mark 2 in box; for a hospital mark 3 in box; for a laboratory (private or public) mark 4 in box; for a clinic mark 5 in box; for other, e.g., nurse, other health care professional, judge; mark 6 in box and specify on the line provided.

TESTING FACILITY DATA

11. NAME OF LABORATORY: Enter the name of the laboratory analyzing the blood lead sample. The laboratory code number will be completed by the Illinois Department of Public Health.

12. ADDRESS: Enter the address of the laboratory analyzing the blood lead sample including street number, direction and name.

CITY: Enter the complete name of the city of laboratory analyzing the blood lead sample.

STATE: Enter the two digit abbreviation of the state of the laboratory analyzing the blood lead sample.

ZIP CODE: Enter the five digit zip code of the laboratory analyzing the blood lead sample.

13. LABORATORY TELEPHONE NUMBER: Enter the telephone number of the laboratory analyzing the blood lead sample.

14. TEST RESULTS: Enter the blood lead level of the sample in micrograms per deciliter (mcg/dl).

15. DATE SAMPLE COLLECTED: Enter the month, day and year the blood lead sample was collected, e.g., 08/03/1989. Use two digits for month and day. Use four digits for the year.

16. DATE SAMPLE RECEIVED: Enter the month, day and year the blood lead sample was received by the laboratory, e.g., 08/03/1989. Use two digits for month and day. Use four digits for the year.

17. DATE SAMPLE ANALYZED: Enter the month, day and year the blood lead sample was analyzed by the laboratory, e.g., 08/03/1989. Use two digits for month and day. Use four digits for the year.

18. SPECIMEN TYPE: Enter a l in the box provided if the specimen type is venous; and 2 if capillary and a 9 if unknown.

19. METHODOLOGY: Enter appropriate methodology used. Enter a 1 in the box for delves cup; a 2 for extraction-AAS; a 3 for carbon rod-AAS; a 4 for graphite furnace-AAS; a 5 for anodic stripping voltammetry; a 6 for hematoflourometry; a 7 for other methodology used and specify on the line provided.

On the line provided on the form, the signature of the person (first & last name), completing the form should be affixed. Enter the title of the person completing the form. Enter the date the completed form is mailed.

Mail completed report within 7 business days to:

Illinois Department of Public Health

Division of Epidemiologic Studies

Occupational Disease Registry

605 West Jefferson Street

Springfield, IL 62761

(Source: Added at 14 Ill. Reg. 5495, effective April 1, 1990)

Section 840.APPENDIX C Forms and Instructions for Occupational Disease Registry

Section 840.EXHIBIT B Instructions for completing the Health Department Follow-up Report of Adult Blood Lead Level Analysis For Results of 25 mcg/dl and Above (Local Health Authorities will use this form)

The follow-up form should be completed for all persons 16 years of age and older having had a blood lead test done and analyzed at 25 mcg/d1 or higher. Information from this form will be matched with the laboratory report of adult elevated blood lead level analysis form.

1. ILLINOIS DEPARTMENT OF PUBLIC HEALTH CASE NUMBER: The case number will be completed by the Illinois Department of Public Health.

2. DATE OF REPORT: Enter the month, day and year the form is being completed, e.g., 08/03/1989. Use two digits for month and date and four digits for the year.

3. HEALTH DEPARTMENT FOLLOW-UP: If not already computer printed, enter the name of the health department completing the report, e.g., Cook County Health Department.

CASE DATA

4. NAME: Information for the case name will be extracted from the Laboratory Based Report of Adult Blood Lead Analysis form. The health department conducting the follow-up activities should verify, correct or complete the information at the time of the case interview.

• LAST NAME: Enter the complete last name of the case.

• FIRST NAME: Enter the complete first name of the case.

• MIDDLE INITIAL: Enter the middle initial of the case.

• MAIDEN NAME: If applicable, enter the maiden name of the case.

ADDRESS: Information for the case address will be extracted from the Laboratory Based Report of Adult Blood Lead Analysis form. The health department conducting the follow-up activities should verify, correct, or complete the information at the time of the case interview. All elements refer to domicile, i.e., the address from which the case may lawfully register vote if proper age is attained.

• NUMBER: Enter the number of case's current street address.

• DIRECTION: Enter the direction which appears in the case's current street address, e.g., North, West.

• STREET NAME: Enter the name of the case's current street address.

• APARTMENT NUMBER: If applicable, enter the apartment number of the case's current address.

• TYPE: Enter the applicable type of street address, e.g. avenue, street, boulevard.

• LOCATION: If applicable, enter the location of the street address, e.g., N.E., N.W.

• CITY: Enter the complete name of the city where the case currently is domiciled.

• STATE: Enter the two digit state abbreviation where the case currently is domiciled.

• ZIP CODE: Enter the five digit zip code where the case's currently domiciled address applies.

• COUNTY NAME AND CODE: Enter the name of county where the case is domiciled. The Illinois Department of Public Health will enter the county code of the case's current address.

PERSONAL DATA

5. PHONE NUMBER: Enter the case's telephone number (area code and seven digit number). Enter slashes if unknown.

6. SOCIAL SECURITY NUMBER: Enter the case's nine digit social security number. If unknown, enter slashes in the boxes provided.

7. DATE OF BIRTH: Enter the case's month, day and year of birth, e.g., 08/03/1989. Use 2 digits for month & date and 4 digits for year.

8. SEX: Enter the case's sex in the box. Mark 1 if male, 2 if female, and 3 if other (includes hermaphrodites and instances of definitive sex changes), and 9 if unknown.

9. RACE: Enter the case's race in the box. Mark 1 if White, 2 if Black, 3 if Asian American/Pacific Islander, 4 if American Indian/Alaskan Native, 5 if other and identify what type on the line provided and box 9 if unknown.

Black is defined as a person having origins in any of the black racial groups of the original people of Africa, and is not of Hispanic origin.

Asian American or Pacific Islander is defined as a person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands, i.e., China, Korea, the Philippine Islands or Samoa.

American Indian or Alaskan Native is defined as a person having origins in any of the original peoples of North America and who maintains culture identification through tribal affiliation or community organization.

White is defined as a person who is considered to be Caucasian.

10. HISPANIC ORIGIN: Hispanic is not considered a race. It is an ethnicity. Enter the appropriate number in the box identifying whether or not case is Hispanic. Mark 1 for yes, if yes, specify ancestry on line provided, mark 2 for no, and mark 9 for unknown. Hispanic Origin includes all Mexican, Puerto Rican, Cuban, South or Central America, and other Spanish people. Brazilians and Portuguese are not considered of Hispanic origin.

11. NUMBER OF CHILDREN UNDER 16 YEARS OF AGE LIVING IN THE CASE'S HOUSEHOLD: Enter the appropriate number of children living in the case's household in the box provided.

12. CASE OR OTHER IN HOUSEHOLD PREGNANT AT TIME OF DIAGNOSIS: If the case or other in household is pregnant at the time the elevated blood level sample is taken indicate by entering a 0 for not appropriate (N/A), 1 for yes, if not pregnant enter a 2 for no, or if unknown enter a 9.

13. TRIMESTER OF PREGNANCY: If the case or other in household is pregnant at the time the elevated blood level sample is drawn enter the trimester by marking 1 for first, 2 for second, 3 for third. If not applicable, enter 0.

CASE OCCUPATION DATA

14. OCCUPATION: Enter the type of occupation which the case is currently or most recently employed. The Illinois Department of Public Health will complete the code.

15. INDUSTRY: Enter the type of industry which the case is currently or most recently employed. The Illinois Department of Public Health will complete the code.

16. IF CASE OR OTHER IN HOUSEHOLD PREGNANT, LIST CASE'S OCCUPATION DURING: (If applicable)

• Prior to 3 months: Enter type of occupation case held 3 months before pregnancy. The Illinois Department of Public Health will complete the code.

• 1^st Trimester: Enter the type of occupation case held at 1st trimester of pregnancy. The Illinois Department of Public Health will complete the code.

• 2^nd Trimester: Enter the type of occupation case held at 2nd trimester of pregnancy. The Illinois Department of Public Health will complete the code.

• 3^rd Trimester: Enter the type of occupation case held at 3rd trimester of pregnancy. The Illinois Department of Public Health will complete code.

17. CASE REMOVED FROM WORK ENVIRONMENT: Enter 1 for yes - case was removed from work environment or 2 for no - case was not removed from work environment. Enter 9 if it is unknown whether case was removed from work environment.

CASE EMPLOYER DATA

18. COMPANY NAME: Enter the name of the case's current or most recent employer at the time the blood test was drawn. The Illinois Department of Public Health will complete the code.

EMPLOYER'S ADDRESS (The work site of the case):

• NUMBER: Enter the number and direction of the case's current or most recent employer.

• STREET NAME: Enter the street name of the case's current or most recent employer.

• CITY: Enter the complete name of the city of the case's current or most recent employer.

• STATE: Enter the two letter abbreviation of the state (see attached list) of the case's current or most recent employer.

• ZIP CODE: Enter the five digit zip code of the case's current or most recent employer.

• COUNTY NAME AND CODE: Enter the county name of the case's current or most recent employer. Illinois Department of Public Health will complete the county codes.

19. EMPLOYER'S PHONE NUMBER: Enter the telephone number of the case's current or most recent employer (includes area code and seven digits).

SIGNATURE LINE: Enter the name (first and last) of the person completing the report. Enter the title of the person completing the report. Record on the line provided the date the completed report is mailed.

Mail completed form within 30 business days after receipt of the Adult Elevated Blood Lead Report to:

Illinois Department of Public Health

Division of Epidemiologic Studies

Occupational Disease Registry

605 W. Jefferson Street

Springfield, IL 62761

(Source: Amended at 17 Ill. Reg. 2319, effective February 10, 1993)

Section 840.APPENDIX C Forms and Instructions for Occupational Disease Registry

Section 840.ILLUSTRATION A Health Department Laboratory Report of Adult Elevated Blood Lead Analysis 25 mcg/dl and Above

LABORATORY REPORT OF ADULT

ELEVATED BLOOD LEVEL ANALYSIS 25 mcg/dl AND ABOVE

(Please PRINT Firmly)

2. Reporting Date

IDPH Case Number

CASE DATA

Name

Last Name

First Name

Maiden (If Applicable)

Number

Dir

Street Name

Apt

Type

Loc

City

State

Zip Code

County Name

County Code

TESTING FACILITY DATA

11.

Laboratory Name

Phone Number

Sex

1. Male

2. Female

3. Other

4. Unknown

12.

Address

Date of Birth

City

State

Zip Code

FOR IDPH USE ONLY

Follow-up LHO

13.

Laboratory Telephone Number

Occupation

Industry

14.

Test Results

mcg/dl

SUBMITTING PARTY DATA

15.

Date Sample Collected

Name

16.

Date Sample Received

Title

17.

Date Sample Analyzed

Phone Number

18.

Specimen Type:

10.

Type:

Venous

Physician

Lab

Capillary

Industry

Clinic

Unknown

Hospital

Other

19.

Methodology:

Delves cup

MAIL TO:

Extraction-AAS

^{ILLINOIS DEPARTMENT OF PUBLIC HEALTH}

^{OCCUPATIONAL DISEASE REGISTRY}

^{605 WEST JEFFERSON STREET}

^{SPRINGFIELD, IL 62761}

^{TELEPHONE: (217)785-1873}

Carbon rod-AAS

Graphite furnace-AAS

Anodic stripping voltommetry

Hematofluorometry

Other:

20.

Signature of Person Completing Form

Title

Date

(Source: Added at 14 Ill. Reg. 5495, effective April 1, 1990)

Section 840.APPENDIX C Forms and Instructions for Occupational Disease Registry

Section 840.ILLUSTRATION B Health Department Follow-Up Report of Adult Blood Lead Levels Analysis for Results of 25 mcg/dl and Above

11/13/89

HEALTH DEPARTMENT FOLLOW-UP REPORT OF ADULT BLOOD LEAD LEVEL ANALYSIS FOR RESULTS OF 25 mcg/dl AND ABOVE

(Please PRINT firmly or type)

1. IDPH case #

DATE OF REPORT:

3. HEALTH DEPT.

/ /

FOLLOW-UP:

month

day

year

CASE DATA

NAME:

last name

first name

middle initial

maiden (if applicable)

ADDRESS

number

dir

street name

apt

type

loc

city

state

zip code

county

PERSONAL DATA

CASE OCCUPATION DATA

IDPH

only

PHONE NUMBER

Sex

14.

OCCUPATION:

1. Male

2. Female

3. Other

4. Unknown

SOCIAL SECURITY NUMBER

15.

INDUSTRY:

- -

Date of Birth

16.

IF CASE OR OTHER IN HOUSEHOLD PREGNANT LIST THE CASE'S OCCUPATION DURING:

/ /

month

day

year

Prior 3 months:

RACE:

10.

HISPANIC

1^st trimester:

1. White

ORIGIN:

2^nd trimester:

2. Black

1. Yes

3^rd trimester:

3. Asian/Pacific Islander

Specify

17.

CASE REMOVED FROM

1. Yes

4. American Native

WORK ENVIRONMENT?

2. No

5. Other

2. No

CASE EMPLOYER DATA

9. Unknown

18.

COMPANY NAME:

11.

NUMBER OF CHILDREN UNDER 16 YEARS OF AGE LIVING WITH CASE:

12.

CASE OR OTHER IN

13.

TRIMESTER OF

HOUSEHOLD PREGNANT

PREGNANCY:

number

street name

AT TIME OF DIAGNOSIS:

1. First

0. N/A

2. Second

city

state

zip code

county

1. Yes

3. Third

2. No

19.

EMPLOYER PHONE NUMBER

9. Unknown

MAIL TO:

^{ILL. DEPARTMENT OF PUBLIC HEALTH}

^{OCCUPATIONAL DISEASE REGISTRY}

^{605 West Jefferson}

^{Springfield, Illinois 62761}

^{TELEPHONE: (217)785-1873}

Signature of Person Completing Form

Title

Date

(Source: Added at 14 Ill. Reg. 5495, effective April 1, 1990)

Section 840. APPENDIX C Forms and Instructions for Occupational Disease Registry

Section 840.ILLUSTRATION C Occupational Disease Registry Abstract Information from the Illinois Health Care Cost Containment Council (Repealed)

(Source: Repealed at 31 Ill. Reg. 12207, effective August 2, 2007)