Maryland Department Of Health And Mental Hygiene Blood Lead Testing Certificate Template
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2MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE BLOOD LEAD TESTING CERTIFICATE
CHILD'S NAME_______________________________________/_______________________/___________________________
LAST
FIRST
MIDDLE
CHILD’S ADDRESS ____________________________________/______________________/______________/_____________
ADDRESS
CITY
STATE
ZIP
SEX:
MALE
FEMALE
BIRTHDATE___________/_________/________
COUNTY ________________________________ SCHOOL________________________________________ GRADE________
PARENT
______________________________/_______________________/__________________/____________________
OR
LAST
FIRST
MIDDLE
PHONE
GUARDIAN ________________________________________/_______________________/______________/______________
ADDRESS
CITY
STATE
ZIP
CERTIFICATION INFORMATION
The following applies to blood lead testing requirements and the duties of health care providers, parents/guardians, and the public
schools:
1.
The health care provider for a child who resides in an at-risk area, or has ever resided in an at-risk area as designated by the
Maryland Targeting Plan for Childhood Lead Poisoning, shall administer a blood test for lead poisoning during the 12-month
visit and again during the 24-month visit. At-risk areas by Zip Code are listed on the back of this form.
2.
Beginning not later than September 2003, the parent or guardian of a child who currently resides, or has ever resided, in an at-
risk area, shall provide to the designated administrator of the child’s school or program, evidence that the child has had blood
lead testing, on entry into a Maryland public pre-kindergarten program or Maryland public school system at the level of pre-
kindergarten, kindergarten or first grade.
3.
Evidence of blood testing for lead poisoning sent to or received by a program or school shall be documented on a form approved
by the Department that includes the following: name of the child, address of the child, date of the blood test(s) for lead
poisoning, and the signature of the child’s health care provider or designee, or school health professional or designee that
transcribed the information onto the approved form.
4.
A list of children (including home contact information) whose parent/guardian does not comply with the requirement to provide
evidence of blood lead testing, must be forwarded to the Local Health Department in the jurisdiction where the child resides.
RECORD OF BLOOD LEAD TESTING
Test #1. ___________
Test # 2. ___________
Comments: _______________________________________________
Date
Date
Signature ___________________________________________________________/__________
Health Care Provider or Designee OR School Health Professional or Designee
Date
RECORD OF BLOOD LEAD TESTING EXEMPTION
I, _______________________________ certify that my child does not AND has never resided in an at-risk area.
Parent or Guardian (Print)
Signature__________________________________________________
/ __________
Parent or Guardian
Date
COMPLETE THE SECTION BELOW IF THE CHILD IS EXEMPT FROM LEAD TESTING ON RELIGIOUS GROUNDS. ANY LEAD TESTS
THAT HAVE BEEN ADMINISTERED SHOULD BE ENTERED ABOVE. A LEAD RISK ASSESSMENT QUESTIONNAIRE MUST BE
ADMINISTERED BY A HEALTH CARE PROVIDER IF THE CHILD IS EXEMPT FROM LEAD TESTING ON RELIGIOUS GROUNDS.
RELIGIOUS OBJECTION:
1.
I am the parent/guardian of the child identified above. Because of my bona fide religious beliefs and practices, I object to any blood lead
testing of my child. Signed __________________________________________ / ___________
Parent or Guardian
Date
2.
Lead Risk Assessment Questionnaire Administered: YES
NO
Signed__________________________________/_______
Health Care Provider
Date
DHMH #4620 Revised May 2004
Maryland Department of Health and Mental Hygiene, Center for Maternal and Child Health
410.767.6713
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