Please fill out completely for all
pt.’s and send after the 2nd
specimen or confirmed BLL result
has been filled in.
Confirmed specimen: venous
2nd capillary
Childhood Lead Poisoning Prevention Program
(CLPPP) Report Form
Please send copy to CLPPP
and place this form in the
Medical Chart. Any updates
made on this page please send
updated form to:
Lead Case Manager
275 E. Main Street HS2WA
Frankfort, KY 40621
or fax to: 502-564-8389
County/Health Dept: ___________________________________________
Case Manager: ________________________________________Phone #:__________________
Name of Child: ___________________________________________DOB:__________________
Pt. Address:_____________________________________________Zip Code:__________________
Payer source: ___________________________Medicaid: Yes /
No
#_______________
Parent/Guardian: ________________________Relationship to child: _______________________
Guardian Ph #:__________________________Alternative Phone #:________________________
Physician: ______________________________________Phone #:________________________
Initial BLL:
________ Venous / Capillary__________µg/dL
Date: ________ Venous / Capillary _________ µg/dL
Date:
Confirm BLL:
If Initial Blood Lead level is greater
than 10 ug/dL and not a venous, you
must get a confirmed BLL.
Verbal Risk Assessment: Child:_____Prenatal:______PerformedDate:________Positive:_____Negative:_____
 Family Relocated:
Yes ______No________ Relocation Address: _____________________________________________
____________________________________________________________________________________________________
Class IIA: Blood Lead Levels at 10-14 µg/dL:
Repeat BLL q 12 weeks until <10 ug/dl
Home Visit if second specimen remains at this level.
 Parent notified of Blood Lead Level?
 Parent Education:
C
L
A
S
S
I
I
A




Date Notified: __________
Pamphlets given and reviewed with parent:
____Lead Poisoning: Are Your Children at Risk?
____Prevent Lead Poisoning: Eat Healthy
____Pregnancy and Lead
____Other:____________________________________
 Refer for WIC Services:
Date:________RN initials:__________
Date:________RN initials:__________
Date:________RN initials:__________
Date:________RN initials:__________
Ref / Appt: Date: ________________
Home Visit if second specimen remains at this level.
 Home Visit
Visual Assessment
/
Draw Blood Lead Level
(Circle one or both)
Per: RN: ____________________Environmentalist:________________ Date Performed: _______
Must make a HV with 2nd level >10 or any confirmed level >15 µg/dL
For Levels:
10-14 µg/dL within 2 weeks
45-69 µg/dL within 48 hours
15-44 µg/dL within 1 week
>70 µg/dL within 24 hours
 Family Relocated: Yes ______No________
RelocationAddress: ______________________________________________________________________________
Lead-4 07/08
Please fill out completely and
send after the 2nd specimen or
confirmed BLL result has been
filled in.
Confirmed specimen: venous
2nd
capillary
Childhood Lead Poisoning Prevention Program
(CLPPP) Report Form
Please send copy to CLPPP
and place this form in the
Medical Chart. Any updates
made on this page please send
updated form to:
Lead Case Manager
275 E. Main Street HS2WA
Frankfort, KY 40621
or fax to: 502-564-8389
County/Health Dept: _________________________________________________________
Case Manager: _________________________________________Phone #:____________________
Name of Child: __________________________________________DOB:______________________
C
L
A
S
S
I
I
B
&
I
I
I
C
L
A
S
S
I
V
Class IIB &III: Blood Lead Levels 15-44 µg/dL:
Repeat BLL q 1-2 months
Continue with ALL of the above interventions in addition to;
 Medical Nutrition Therapy:
Appt Date:________________/ Completed_________________
 Refer to PCP for Medical Evaluation: Referral Date: __________________________________________
Performed by Physician: __________________
Medical Evaluation Date Completed: _______________
 Refer to Certified Risk Assessor:
Performed by: Certified Risk Assessor Name:
Referral Date:___________________________________
Assessment Date with Samples Taken: ______________
Hazards Identified:__________________________
_________________________________________
(A Certified Risk Assessor is an Environmentalist who has been certified to take lead samples, if your Local Health Department or district
does not have a Certified Risk Assessor, please contact the Childhood Lead Poisoning Prevention Program at 502-564-2154)
 Family Relocated: Yes ______No________
RelocationAddress:______________________________________________________________________________
Class IV: Blood Lead Levels 45-69 µg/dL:
Repeat BLL in 48 hours
Continue with ALL of the above interventions in addition to;
BLL:
Confirm BLL:
Date: ________Venous / Capillary_____µg/dL
Date: ________Venous / Capillary _____ µg/dL
A venous specimen in a purple top is needed before
initiating Chelation Therapy. Please refer
immediately to the PCP if your HD does not draw
venous lab specimens.
 Venous specimen submitted within 48 hours ~~~~~~~~~~~~~~~~~~ Date 2nd specimen received:______
 Refer to PCP for Medical Evaluation and possible chelation ~~~ Date Referred:_________________
 If referred to Specialist by PCP for chelation therapy: ~~~~~~~~~ Referred to____________________
~~~~~ Date: _________________________
~~~~~ Chelation Date Started: _________
If Chelation therapy initiated, BLL’s will need to be drawn q month during and post chelation until:
*BLL <10µg/dL for 6 months
C
L
A
S
S
V
* Hazards have been removed and there are no new hazards * As ordered by the physician
Class V: Blood Lead Levels 70 µg/dL and greater:
Repeat BLL in 24 hours
Continue with ALL of the above interventions in addition to:
BLL:
Confirm BLL:
A venous specimen in a purple top is needed before
initiating Chelation Therapy. Please refer patient
immediately to the PCP for Medical Evaluation.
Date: ________Venous / Capillary______µg/dL
Date: ________Venous / Capillary _____ µg/dL
 Venous specimen submitted within 24 hours~~~~~Date 2nd specimen received: __________
 Referred to PCP for Medical Evaluation while awaiting results of confirmatory~~Date: _______Time:_________
 If referred to Specialist by PCP for chelation therapy: Referred to_________________Date:_________________
Chelation Date Started:______________
Lead-4 07/08
Fill out with monthly updates
and fax or mail copy to
KY CLPPP
Childhood Lead Poisoning Prevention Program
(CLPPP) Monthly Report Form
Place this form in the Medical Chart.
Any updates made on this page
please send updated form to:
Lead Case Manager
275 E. Main Street HS2WA
Frankfort, kY 40621
or fax to: 502-564-8389
County/Health Dept: _____________________________________________________________
Case Manager: _________________________________________Phone #:_________________
Name of Child: __________________________________________DOB:___________________
Date
F/U BLL
Test
Results
Action/Interventions
Please fill out information legibly in appropriate boxes, and place BLL test results in results box only
PHPR Guidelines to Case Closure:
 BLL <10 µg/dL for Class I and BLL <10 µg/dL for 6 months on Classes II and greater
 Hazards have been removed and there are no new hazards
Date closed to follow-up:
Reason closed:
Administrative Closure procedures followed:
Phone call:
Date & Response:_
Letter:
Date & Response:
Certified Letter: Date & Response:
Case Manager Signature:
Lead-4 07/08