Section 845.APPENDIX A   Instructions for Childhood Blood Lead Poisoning Reporting System

Section 845.EXHIBIT A   Instructions for Completing the Laboratory-Based Report of Childhood Lead Poisoning

The Childhood Lead Poisoning Report form shall be completed for all blood lead test results on all persons 15 years of age and younger. Each laboratory in Illinois certified by the Department to conduct a blood lead analysis is required to complete the Childhood Lead Poisoning Report form, unless the laboratory is reporting to the Department using the electronic reporting system.

1)         Complete the following information on the child's complete name:

LAST NAME: Enter the child's complete last name.

FIRST NAME: Enter the child's complete first name.

MIDDLE INITIAL: Enter the child's middle initial.

2)         Complete the following information on the child's parent or guardian, if available:

LAST NAME: Enter the parent/guardian's complete last name.

FIRST NAME: Enter the parent/guardian's complete first name.

MAIDEN NAME: Enter the parent/guardian's complete maiden last name.

3)         TELEPHONE NUMBER: If available, enter the child's telephone number (area code and 7-digit number).

4)         DATE OF BIRTH: Enter the child's date of birth.  Use 2 digits for the month, 2 digits for the day and 2 digits for the year (e.g., 01/01/01).

5)         ADDRESS OF CHILD: Complete the following elements on the form.  All elements refer to the current address for the child.

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

DIRECTION: Enter the direction that appears in the child's current street address (e.g., North).

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

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

APARTMENT NUMBER: If applicable, enter the apartment number of the child's address.

COUNTY: Enter the complete name of the county where the child currently resides.

CITY: Enter the complete name of the city where the child current resides.

STATE: Enter the state where the child currently resides.  Use the standard 2-character abbreviation.

ZIP: Enter the 5-digit zip code where the child currently resides.

6)         SEX: Check the appropriate box to indicate the child's sex.

7)         RACE: Check the appropriate box to indicate the child's race.

8)         HISPANIC: Check the appropriate box to indicate whether the child is Hispanic.

TEST DATA

1)         DATE OF FIRST TEST: Enter the month, day and year the first blood lead sample to be reported was collected.  Use 2 digits for the month, 2 digits for the day and 2 digits for the year (e.g., 01/01/01).

2)         TYPE: Check the appropriate box to indicate the specimen type (venous or capillary).

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

4)         DATE OF SECOND TEST: Enter the month, day and year that the second blood lead sample to be reported was collected.  Use 2 digits for the month, 2 digits for the day and 2 digits for the year (e.g., 01/01/01).

5)         TYPE: Check the appropriate box to indicate the specimen type (venous or capillary).

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

7)         NAME OF LABORATORY: Enter the name of the laboratory analyzing the blood lead sample or the laboratory code number.

8)         LABORATORY TELEPHONE NUMBER: Enter the telephone number of the laboratory that analyzed the blood lead sample.

SUBMITTING PARTY DATA

1)         NAME: Enter the name of the physician, hospital staff member, laboratory technician, clinic employee or other person submitting the report of blood lead results.

2)         TELEPHONE NUMBER: Enter the telephone number of the submitting party (area code and 7-digit number).

3)         CLINIC/HOSPITAL: Enter the name of clinic or hospital.

4)         ADDRESS: Enter the address of the physician, hospital, laboratory, clinic or other person/facility submitting the report of the blood lead test.  The street number, direction, street name, suite, city, state, zip code and county shall be included.

COMPLETION DATA

1)         SIGNATURE/TITLE: On the line provided on the form, the usual signature of the person (first and last name) completing the form shall be affixed.  Enter the title of the person completing the form.

2)         DATE OF REPORT: Enter the month, day and year the form is completed.  Use 2 digits for the month, 2 digits for the day and 2 digits for the year (e.g., 01/01/01).

All elevated blood lead levels of 45 mcg/dL shall be reported by telephone within 24 hours to the Childhood Lead Poisoning Prevention Program at (217) 785-9464 or (217) 782-0403.

Mail completed report within 48 hours to:

Illinois Department of Public Health

Division of Health Assessment and Screening

Childhood Lead Poisoning Prevention Program

535 West Jefferson Street

Springfield, Illinois 62761