MDCH Blood Lead Analysis Report Form - State of Michigan

MICHIGAN DEPARTMENT OF COMMUNITY HEALTH BLOOD LEAD ANALYSIS REPORT DATA/INFORMATION REQUIRED BY ADMINISTRATIVE RULE # R325.9082 AND R 325.9083 PATIENT INFORMATION To be completed by Parent/Guardian or Patient PLEASE PRINT __________________________________________ Last Name

_____________________________________________ First Name

_______________________________________ Address – No PO Boxes, please __(_____)_____________________ Area Code and Phone Number

________ Apt. #

Race (Check all that apply): □ American Indian or Alaskan Native □ Asian □ Black or African American □ Native Hawaiian or Other Pacific Islander □ White □ Hispanic or Latino □ Middle Eastern or Arabic

__MI___ State

_______________________ City

________________________ Birthdate (month/day/year)

_________ M. Initial

_____________ Zip

_____________________________________ Parent/Guardian Name (please print)

Sex:

□ Male □ Female

If Patient is an adult (≥ 16 years):

Employer: ___________________________ Funding Sources: □ Self Pay/Insurance Social Security #: _____________________ □ Medicaid ID# (Medicaid only): _________________________

PROVIDER/PHYSICIAN INFORMATION To be completed by provider’s office ____________________________________ Clinic, Hospital or Agency Name

___________________________________________ Physician name

____________________________________ Mailing Address

___________________________ City

_(_____)______________________________ Area Code and Phone Number

______________________________ Fax Number

__________ State

___________ Zip

SPECIMEN COLLECTION INFORMATION To be completed by person who draws specimen ______________________________ Specimen Collection Date

Source of Specimen

□ Capillary

□ Venous

□ Filter Paper

LABORATORY INFORMATION To be completed by testing laboratory ____________________________________ Laboratory Name

_________________________________ Specimen ID Number

(______)____________________________ Area Code and Phone Number

_________________________________ Analysis Date

BLOOD LEAD LEVEL in Micrograms per Deciliter _________________ (round to nearest whole number, please) MDCH – Childhood Lead Poisoning Prevention Project, 109 W. Michigan Ave., PO Box 30195, Lansing, MI 48909 DCH-0395 (October 2009) Authority: Act 368, PA 1978

(517) 335-8885 Fax (517) 335-8509