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

EXHIBIT A Instructions for Completing the Laboratory Based Report of Childhood Lead Poisoning

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

CHILD DATA

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 compete 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 last maiden name.

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

4. DATE OF BIRTH: Enter the child's date of birth. Use two digits for the month, date and year.

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 child's current street address.

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

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

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

• 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 is residing.

• CITY: Enter the complete name of the city in which the child currently is residing.

• STATE: Enter the state where the child currently is residing. Use the standard two-character abbreviation.

• ZIP: Enter the five-digit zip-code where the child currently is residing.

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

9. DATE OF FIRST TEST: Enter the month, day, and year the first blood lead sample to be reported was collected. Use two digits for month, day, and year, e.g., 06/01/92.

10. TYPE: Check the appropriate box to indicate the specimen type (venous or fingerstick).

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

12. DATE OF SECOND TEST: Enter the month, day, and year the second blood lead sample to be reported was collected. Use two digits for month, day, and year, e.g., 06/01/92.

13. TYPE: Check the appropriate box to indicate the specimen type.

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

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

16. LABORATORY TELEPHONE NUMBER: Enter the telephone number of the laboratory which analyzed the blood lead sample.

SUBMITTING PARTY DATA

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

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

19. CLINIC/HOSPITAL: Enter name of clinic or hospital.

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

COMPLETION DATA

21. On the line provided on the form, the usual signature of the person (first and last name) completing the form should be affixed. Enter the title of the person completing the form.

22. DATE OF REPORT: Enter the month, day, and year the form is completed. Use two digits for month, day, and year, e.g., 06/01/92.

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 Family Health

Childhood Blood Lead Level Reporting System

535 West Jefferson Street

Springfield, IL 62761

(Source: Amended at 21 Ill. Reg. 7444, effective May 31, 1997)

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

Section 845.EXHIBIT B Instructions for Submitting Follow-Up Data for Children With Blood Lead Levels ≥15 mcg/dL

Medical follow-up should be completed by delegate agencies for all persons 15 years of age and younger having had a blood lead test analyzed and confirmed at 15 mcg/dL or higher.

All medical and environmental follow-up data must be entered into a STELLAR database maintained by the delegate agency. A STELLAR report and any additional reports requested by the Illinois Department of Public Health should be run regularly, at intervals determined by the Department. Detailed instructions on the STELLAR procedures are available from the Department upon request.

(Source: Amended at 21 Ill. Reg. 7444, effective May 31, 1997)

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

Section 845.EXHIBIT C Instructions for Reporting Information by Delegate Agencies on Environmental Inspection for Cases of 20 mcg/dl and Above (Repealed)

(Source: Repealed at 21 Ill. Reg. 7444, effective May 31, 1997)