Dhmh Form 4620 - Hygiene Blood Lead Testing Certificate (Page 2 of 2) in pdf

HOW TO USE THIS FORM

The documented tests should be the blood lead tests at 12 months and 24 months of age. Two test dates and results are required

if the first test was done prior to 24 months of age. If the first test is done after 24 months of age, one test date with result is

required. The child’s primary health care provider may record the test dates and results directly on this form 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.

At Risk Areas by ZIP Code from the 2004 Targeting Plan (for children born

BEFORE January 1, 2015)

Prince George’s

Queen Anne’s

Baltimore Co.

Frederick

Allegany

(Continued)

Carroll

(Continued)

Kent

(Continued)

21212

21155

21776

21610

20737

21640

ALL

21215

21757

21778

21620

20738

21644

Anne Arundel

21219

21776

21780

21645

20740

21649

21220

21787

21783

21650

20741

21651

20711

20714

21221

21791

21787

21651

20742

21657

20764

21222

21791

21661

20743

21668

20779

21224

Cecil

21798

21667

20746

21670

21060

21227

21913

20748

21061

21228

Garrett

Montgomery

20752

Somerset

21225

21229

Charles

ALL

20783

20770

ALL

21226

21234

20640

20787

20781

St. Mary’s

21402

21236

20658

Harford

20812

20782

21237

20662

21001

20783

20606

20815

Baltimore Co.

21239

21010

20784

20626

20816

21027

21244

Dorchester

21034

20785

20628

20818

21052

21250

ALL

21040

20838

20787

20674

21071

21251

21078

20842

20788

20687

21082

21282

Frederick

21082

20868

20790

21085

21286

20842

21085

20877

20791

Talbot

21093

21701

21130

20901

20792

21612

21111

Baltimore City

21703

21111

20910

20799

21654

21133

ALL

21704

21160

20912

21657

21155

21716

21161

20913

21665

21161

Calvert

21718

21671

Prince George’s

Queen Anne’s

21204

20615

21719

Howard

21673

21206

20714

21727

20763

20703

21676

21607

21207

21757

20710

21617

21208

Caroline

21758

20712

Washington

21620

21209

ALL

21762

20722

ALL

21623

21210

21769

20731

21628

Wicomico

ALL

Worcester

ALL

Lead Risk Assessment Questionnaire Screening Questions:

Lives in or regularly visits a house/building built before 1978 with peeling or chipping paint, recent/ongoing renovation or

remodeling?

Ever lived outside the United States or recently arrived from a foreign country?

Sibling, housemate/playmate being followed or treated for lead poisoning?

If born before 1/1/2015, lives in a 2004 “at risk” zip code?

Frequently puts things in his/her mouth such as toys, jewelry, or keys, eats non-food items (pica)?

Contact with an adult whose job or hobby involves exposure to lead?

Lives near an active lead smelter, battery recycling plant, other lead-related industry, or road where soil and dust may be

contaminated with lead?

Uses products from other countries such as health remedies, spices, or food, or store or serve food in leaded crystal, pottery or

pewter.

DHMH F

4620

5/2016

ORM

EVISED

EPLACES ALL PREVIOUS VERSIONS

Dhmh Form 4620 - Hygiene Blood Lead Testing Certificate Page 2

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