NOTIFICATION OF LEAD
POISONING
Patient details (please print in BLOCK LETTERS)
First Name
Surname
DOB
 Male  Female
Postcode
Full Address
Occupation
Blood lead level (µg/dl)
Date of presentation
Reason for testing
 Screening
 Diagnosis (symptomatic)
Suspected exposure/source(s)
Notifying doctor details
Name of notifying doctor
First Name:
Surname:
Name of facility at which diagnosis was made:
Address:
Has the patient been advised that this
Notification will be submitted to the Department
of Health?
Phone Number:
 Yes
 No
I hereby notify the Executive Director, Public Health, under the Health (Notification of Lead
Poisoning) Regulations 1985, that the abovementioned patient is or may be suffering from lead
poisoning.
Notifying Doctor Signature
Date
Notifications should be forwarded to: Executive Director, Public Health, Department of Health,
PO Box 8172 PERTH BUSINESS CENTRE WA 6849
Enquiries: Telephone: 08 9222 2380, Facsimile: 08 9222 2322