Form F09-11709 - Confidential Medical Record - Childhood Blood Lead Level Report
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1Childhood Blood Lead Level Report
F09-11709
Confidential Medical Record
Send to:
From:
Texas Childhood Lead Poisoning Prevention Program
Provider Name:
Texas Department of State Health Services
PO Box 149347, MC1964
Austin, TX 78714
City/State/ZIP:
Fax Number:
(512) 776-7699
Phone Number:
(512) 776-6632 or
Phone Number: (
)
1-800-588-1248 (Toll-free)
Fax Number:
(
)
Child Information
Last Name:
First Name:
M.I.
Gender: Male
Female
Date Birth: _____ / _____ / _____
Age in Months:
Medicaid# /CHIP ID#:
Current Address:
Apartment #:
City:
State:
Zip:
Ethnicity: (check one)
Hispanic
Non-Hispanic
Unknown
Child Race: (check one)
White
Black
Asian or Pacific Islander
Native American or Alaskan Native
Multi-Racial
Unknown
Blood Lead Level Information
Blood Lead Test Level:
micrograms per deciliter(mcg/dL)
Blood Draw Date: _____ / _____ / _____
Type of Blood Sample: (check one)
Capillary
Venous
Unknown
If Using LeadCare System, Place Label Here
Testing Laboratory:
Laboratory Phone: (
)
Attending Physician Information
Last Name:
First Name:
Location (City):
For TX CLPPP Use Only
Person Receiving Report:
Date Received: _____ / _____ / _____
Texas Childhood Lead Poisoning Prevention Program
PO BOX 149347, MC1964 ▪ Austin, TX 78714-9347 ▪ 1-800-588-1248 ▪
(Rev. 09/17/2015)
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Parent category: Medical