Illinois Department Of Public Health - Arie Crown Hebrew Day School printable pdf download

Illinois Department of Public Health

Childhood Lead Risk Assessment Questionnaire

ALL CHILDREN 6 MONTHS THROUGH 6 YEARS MUST BE ASSESSED FOR LEAD POISONING.

(410 ILCS 45/6.2)

A documented result of a blood lead test or a properly filled out Childhood Lead Risk Assessment

Questionnaire must be attached to a Certificate of Child Health Examination form for purposes of

admission to an Illinois Department of Children and Family Services or state regulated child-care

facility, including those operated by a school district.

Child’s Name ___________________________

Today’s Date_________________________________

Child’s Age _____________ Child’s Birthdate ________________ Child’s ZIP Code _________________

Respond to the following questions by circling the appropriate answer.

R E S P O N S E

1. Is this child eligible for or enrolled in Medicaid, Head Start, KidCare, All Kids

or WIC?

Yes No Don’t Know

2. Does this child have a sibling with a blood lead level of 10 mcg/dL or higher?

Yes No Don’t Know

3. Does this child live in or regularly visit a home that was built before 1978?

Yes No Don’t Know

4. In the past one year, has this child been exposed to repairs, repainting, or

renovation of a home built before 1978?

Yes No Don’t Know

5, Is this child a refugee or an adoptee from any foreign country?

Yes No Don’t Know

6. Has this child ever been to Mexico, Central or South America, Asian

countries (i.e., China or India), or any country where exposure to lead

from certain items could have occurred (for example, cosmetics, home

remedies, folk medicines or glazed pottery)?

Yes No Don’t Know

7. Does this child live with someone who has a job or a hobby that may

involve lead (for example, jewelry making, building renovation or repair,

bridge construction, plumbing, furniture refinishing, or work with automobile

batteries or radiators, lead solder, leaded glass, lead shots, bullets or lead

fishing sinkers)?

Yes No Don’t Know

8. At any time, has this child lived near a factory where lead is used (for

example, a lead smelter or a paint factory)?

Yes No Don’t Know

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If the child has two (2) consecutive blood lead test results that are each less than 10 mcg/dL (with one

test at age 3 or older) and there has been no change in the child’s living conditions, a blood lead test is

not needed at this time.

Test 1: Blood Lead Result_____mcg/dL Date _____ Test 2: Blood Lead Result_____mcg/dL Date _____

Please discuss any questions or concerns with your child’s health care provider. For more information,

call:

Illinois Department of Public Health

Childhood Lead Poisoning Prevention Program

800-545-2200 or 217-782-0403

TTY (hearing impaired use only) 800-547-0466

________________________________________

Signature of Doctor/Nurse

Date

Illinois Department Of Public Health - Arie Crown Hebrew Day School

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