Free Blood Lead Lab Reporting, F-00017 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Public Health F-00017 (01/09)

STATE OF WISCONSIN Bureau of Environmental & Occupational Health Chapter HFS 181 (608) 266-5817

BLOOD LEAD LAB REPORTING
This form is authorized under sections 250.04(3) and 254.13, Wis. Stats. and Chapter HFS 181, Wis. Admin. Code. Completion of this form is mandatory for health care providers and laboratories in reporting of blood lead test results of Wisconsin residents. Failure to report the required information is subject to a forfeiture of up to $1,000 per day of violation or a fine of up to $5,000. Personally identifiable information about the patient will be kept confidential and will be used only for providing services to the patient and for lead hazard reduction. Patient's Name (Last, First, Middle Initial) Date of Birth (mm/dd/yyyy) Race (Check appropriate box) African American Asian Patient's Street Address City County State Alaskan/Native American Hawiian/Pacific Islander White Multiple Races Apartment Number Zip Code Other, Specify Gender Male Female Ethnicity (Check appropriate) Hispanic Non-Hispanic Unknown Medical Assistance Number (If applicable)

Parent / Guardian (Last, First, Middle Initial) (If patient is under 18 years of age) Telephone Number of Patient or Parent / Guardian (If patient is under 18 years of age) Home ( ) Patient's Employer Name (If patient is 16 years of age or older) Employer's Address (Street, City, State, Zip Code) Name of Health Care Provider Address of Provider (Street, City, State, Zip Code) Name of Physician (If different than Health Care Provider) Address (Street, City, State, Zip Code) Date Blood Collected (mm/dd/yyyy) Blood Collection Type (Check One) Venous Telephone Number ( ) Telephone Number ( ) Work ( ) Occupation

Capillary Clinical Laboratory Improvement Amendment Number: Telephone Number ( )

ADDITIONAL INFORMATION TO BE PROVIDED BY THE LABORATORY Laboratory Name Address(Street, City, State, Zip Code) Date of Analysis (mm/dd/yyyy)

*Results

micrograms lead per 100 milliliters of blood

*Results of 45 or more micrograms lead per 100 milliliters of blood must be faxed within 24 hours to Fax No. (608) 267-0402.
Return to: WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Public Health CLPPP/ABLES, Rm 145 P. O. BOX 2659 Madison, WI 53701-2659