Forms


Reporting Forms

Electronic Reporting Form

Used by healthcare providers to submit blood lead test results by electronic submission

Child Blood Lead Reporting Form (F09-11709)  - Revised August 2018
Used by healthcare providers to report blood lead level(s) for children under 15 years of age.

Adult Blood Lead Reporting Form (F09-11624) - Revised January 2012
Used by healthcare providers to report blood lead level(s) for children/adults 15 years of age and older.

Point-Of-Care Blood Lead Testing Report (Pb-111) - Revised February 2016
Used by healthcare providers to report blood lead levels when using an point-of-care blood lead analyzer.


Screening & Testing

2019 Texas Childhood Blood Lead Screening Guidelines (Pb-120)Revised June 2020
Targeted zip codes have one or more associated census tract in which:

  • The percentage of children age 1-2 years old with a blood lead level ≥ 5 mcg/dL is ≥ 3% among those tested in 2016 (Prevalence), or
  • The percentage of residential structures built before 1950 is ≥ 27% (Housing).

Lead Risk Questionnaire (Pb-110) (English Version) - Revised August 2018

The lead risk questionnaire is also included in the "2019 Texas Childhood Blood Lead Screening Guidelines" document, on page 8.


Follow-Up

Follow-up of Initial Elevated Blood Lead Level (Pb-102) - Revised August 2018
Used by healthcare providers for follow-up of elevated blood lead levels of a child.

Physician Checklist for Parent Education Topics (Pb-104) - Revised August 2018
Used by healthcare providers to determine the appropriate lead educational material to provide parents for medical care, environmental intervention, and nutritional intervention.

Reference for Blood Lead Retesting and Medical Case Management (Pb-109) - Revised August 2018
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”.


Environmental Lead Investigation forms 

Pb-101: Request for Environmental Investigation (Pb-101) - Revised August 2018
Used by healthcare providers to request and Environmental Lead Investigation for a child with a venous blood lead level test result of 20 µg/dL and higher, or two separate venous BLL tests collected at least 12 weeks apart in the 10-19 µg/dL range.

Pb-103: Elevated Blood Lead Level Investigation Questionnaire (Pb-103) - Revised August 2018
Used by Lead Risk Assessors to conduct Environmental Lead Investigations.

Last updated July 27, 2020