Maryland Department Of Health And Mental Hygiene Blood Lead Testing Certificate
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2M
D
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B
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ARYLAND
EPARTMENT OF
EALTH AND
ENTAL
YGIENE
LOOD
EAD
ESTING
ERTIFICATE
Instructions: Use this form when enrolling a child in child care, pre-kindergarten, kindergarten or first grade. BOX A is to be
completed by the parent or guardian. BOX B, also completed by parent/guardian, is for a child born before January 1, 2015 who does
not need a lead test (children must meet all conditions in Box B). BOX C should be completed by the health care provider for any
child born on or after January 1, 2015, and any child born before January 1, 2015 who does not meet all the conditions in Box B. BOX
D is for children who are not tested due to religious objection (must be completed by health care provider).
BOX A
-Parent/Guardian Completes for Child Enrolling in Child Care, Pre-Kindergarten, Kindergarten, or First Grade
CHILD'S NAME
/
/
LAST
FIRST
MIDDLE
CHILD’S ADDRESS
/
/
/
STREET ADDRESS (with Apartment Number)
CITY
STATE
ZIP
SEX: Male Female
BIRTHDATE
/
/
PHONE_______________________________________
PARENT OR
/
/
GUARDIAN
LAST
FIRST
MIDDLE
/
/
/
– For a Child Who Does Not Need a Lead Test (Complete and sign if child is NOT enrolled in Medicaid AND the
BOX B
STREET ADDRESS (with Apartment Number)
CITY
STATE
ZIP
answer to EVERY question below is NO):
Was this child born on or after January 1, 2015?
YES
NO
Has this child ever lived in one of the areas listed on the back of this form?
YES
NO
Does this child have any known risks for lead exposure (see questions on reverse of form, and
talk with your child’s health care provider if you are unsure)?
YES
NO
If all answers are NO, sign below and return this form to the child care provider or school.
Parent or Guardian Name (Print): _______________________ Signature: ______________________________ Date: ______________
If the answer to ANY of these questions is YES, OR if the child is enrolled in Medicaid, do not sign
Box B. Instead, have health care provider complete Box C or Box D.
– Documentation and Certification of Lead Test Results by Health Care Provider
BOX C
Test Date
Type (V=venous, C=capillary)
Result (mcg/dL)
Comments
Comments:
Person completing form: Health Care Provider/Designee OR School Health Professional/Designee
_______________________________
________________________________________
Provider Name:
Signature:
Date: ______________________________________
Phone: ____________________________________
Office Address: ______________________________________________________________________________________________________
– Bona Fide Religious Beliefs
BOX D
I am the parent/guardian of the child identified in Box A, above. Because of my bona fide religious beliefs and practices, I object to any
blood lead testing of my child.
Parent
or Guardian Name (Print): _____________________________ Signature: ______________________________ Date: ____________
********************************************************************************************************************
This part of BOX D must be completed by child’s health care provider: Lead risk poisoning risk assessment questionnaire done: YES NO
_______________________________
________________________________________
Provider Name:
Signature:
Date: ______________________________________
Phone: ____________________________________
Office Address: ______________________________________________________________________________________________________
DHMH F
4620
R
5/2016
R
ORM
EVISED
EPLACES ALL PREVIOUS VERSIONS
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