Maryland Department Of Health And Mental Hygiene Blood Lead Testing Certificate Template Page 2
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1
2HOW TO USE THIS FORM
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The documented tests should be the tests at 12 months and 24 months of age. Two test dates are required if the 1
test
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was done prior to 24 months of age. If the 1
test is done after 24 months of age, one test date is required. The child’s
primary health care provider may record the test dates directly on this form (check marks are not acceptable) and
certify them by signing or stamping the signature section. A school health professional or designee may transcribe
onto this form and certify test dates from any other record that has the authentication of a medical provider, health
department, or school. All forms are kept on file with the child’s school health record. 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.
Maryland Childhood Lead Poisoning Targeting Plan
At Risk Areas by Zip Code
Allegany
Baltimore Co. (Cont.)
Frederick . (Cont)
Montgomery (Cont)
Queen Anne’s
ALL
21239
21757
20812
21607
21244
21758
20815
21617
Anne Arundel
21250
21762
20816
21620
20711
21251
21769
20818
21623
20714
21282
21776
20838
21628
20764
21286
21778
20842
21640
20779
Baltimore City
21780
20868
21644
21060
ALL
21783
20877
21649
21061
21787
20901
21651
21225
21791
20910
21657
Calvert
21226
20615
21798
20912
21668
21402
20714
20913
21670
Garrett
ALL
Baltimore Co.
Caroline
Somerset
21027
ALL
ALL
Prince George’s
21052
Harford
20703
21071
Carroll
21001
20710
St. Mary’s
21082
21155
21010
20712
20606
21085
21757
21034
20722
20626
21093
21776
21040
20731
20628
21111
21787
21078
20737
20674
21133
21791
21082
20738
20687
21155
21085
20740
21161
21130
20741
Cecil
21204
21913
21111
20742
Talbot
21206
21160
20743
21612
21207
Charles
21161
20746
21654
21208
20640
20748
21657
21209
20658
20752
21665
Howard
21210
20662
20763
20770
21671
21212
20781
21673
21215
Dorchester
Kent
20782
21676
21219
ALL
21610
20783
21220
21620
20784
21221
Frederick
21645
20785
21222
20842
21650
20787
Washington
21224
21701
21651
20788
ALL
21227
21703
21661
20790
21228
21704
21667
20791
Wicomico
21229
21716
20792
ALL
21234
21718
Montgomery
20799
21236
21719
20783
20912
Worcester
21237
21727
20787
20913
ALL
Maryland Department of Health and Mental Hygiene Blood Lead Testing Certificate
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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