Lead Risk Assessment Questionnaire

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Illinois Department of Public = Health

Childhood Lead Risk Assessment = Questionnaire

ALL CHILDREN 6 MONTHS THROUGH 6 YEARS = OF AGE MUST=20 BE ASSESSED FOR LEAD POISONING
(410 ILCS 45/6.2)

Name: Today's Date:

Age:Birthdate:ZIP Code:

Respond to the following questions by circling the=20 appropriate answer.	R E S P O N S E
	Yes	No	Don't Know
1.	Is this child eligible for or enrolled in Medicaid, Head Start, = All=20 Kids or WIC?
2.	Does this child have a sibling with a blood lead level of 10 = mcg/dL or=20 higher?
3.	Does this child live in or regularly visit a home built before=20 1978?
4.	In the past year, has this child been exposed to repairs, = repainting=20 or renovation of a home built before 1978?
5.	Is this child a refugee or an adoptee from any foreign = country?
6.	Has this child ever been to Mexico, Central or South America, = Asian=20 countries (i.e., China or India), or any country where exposure to = lead=20 from certain items could have occurred (for example, cosmetics, = home=20 remedies, folk medicines or glazed pottery)?
7.	Does this child live with someone who has a job or a hobby that = may=20 involve lead (for example, jewelry making, building renovation or = repair,=20 bridge construction, plumbing, furniture refinishing, or work with = automobile batteries or radiators, lead solder, leaded glass, lead = shots,=20 bullets or lead fishing sinkers)?
8.	At any time, has this child lived near a factory where lead is = used=20 (for example, a lead smelter or a paint factory)?
9.	Does this child reside in a high-risk ZIP code area?

A blood lead test should be performed on = children:

with any "Yes" or "Don't Know" response=20
living in a high-risk ZIP code area

All Medicaid-eligible children should = have a blood=20 lead test at 12 months of age and at 24 months of age. If a = Medicaid-eligible=20 child between 36 months and 72 months of age has not been previously = tested, a=20 blood lead test should be performed.

If there is any "Yes" or = "Don't=20 Know" response; and

there has been no change in the child's living conditions; and=20
the child has proof of two consecutive blood lead test results = (documented=20 below) that are each less than 10 mcg/dL (with one test at age 2 or = older), a=20 blood lead test is not needed at this time.

Test 1: Blood Lead Result: mcg/dL Date: Test 2: Blood = Lead=20 Result: mcg/dL Date

If responses to all the questions are "NO", re-evaluate at every well = child=20 visit or more often if deemed necessary.

Signature of Doctor/Nurse = Date

Illinois Lead=20 Program
866-909-3572 or 217-782-3517
TTY (hearing impaired use = only)=20 800-547-0466
6/07

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3D"Print

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Illinois Department of Public = Health

Childhood Lead Risk Assessment = Questionnaire

ALL CHILDREN 6 MONTHS THROUGH 6 YEARS = OF AGE MUST=20 BE ASSESSED FOR LEAD POISONING(410 ILCS 45/6.2)

ALL CHILDREN 6 MONTHS THROUGH 6 YEARS = OF AGE MUST=20 BE ASSESSED FOR LEAD POISONING
(410 ILCS 45/6.2)