Blood Lead Lab Reporting, F-00017



DEPARTMENT OF HEALTH SERVICESDivision of Public Health F-00017 (01/2020)STATE OF WISCONSINBureau of Environmental & Occupational HealthChapter DHS 181608-266-5817BLOOD LEAD LAB REPORTINGThis form is authorized under sections 250.04(3) and 254.13, Wis. Stats. and Chapter DHS 181, Wis. Admin. Code. Health care providers and laboratories are required to report all blood lead test results and all other information shown on this form if they obtain or analyze blood to determine lead in blood. Failure to report all this information within the required time limits is subject to forfeiture of up to $5,000 per day of violation. The Department of Health Services will keep personally identifiable information about the patient confidential and will use these data only for legally authorized purposes.Patient’s Last NameFirst NameMiddle Initial FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Date of Birth (mm/dd/yyyy)SexEthnicity (Check Appropriate Box) FORMTEXT ????? FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX Hispanic or Latino FORMCHECKBOX Not Hispanic or Latino FORMCHECKBOX UnknownRace (Mark all that apply) FORMCHECKBOX American Indian or Alaska Native FORMCHECKBOX Asian FORMCHECKBOX Black or African American FORMCHECKBOX Native Hawaiian or Other Pacific Islander FORMCHECKBOX White FORMCHECKBOX Unknown FORMCHECKBOX Other, specify: FORMTEXT ????? Patient’s Street AddressApartment Number FORMTEXT ????? FORMTEXT ?????CityCountyStateZip Code FORMTEXT ????? FORMTEXT ????? FORMTEXT ?? FORMTEXT ?????Parent / Guardian (Last, First, Middle Initial) (If Patient is Under 18 Years of Age) FORMTEXT ?????Telephone Number of Patient or Parent / Guardian (If Patient is Under 18 Years of Age)Home: FORMTEXT ???- FORMTEXT ???- FORMTEXT ????Work: FORMTEXT ???- FORMTEXT ???- FORMTEXT ????Patient’s Employer Name (If Patient is 16 Years of Age or Older)Occupation FORMTEXT ????? FORMTEXT ?????Employer’s Address (Street, City, State, Zip Code) FORMTEXT ?????Name of Health Care ProviderTelephone Number FORMTEXT ????? FORMTEXT ???- FORMTEXT ???- FORMTEXT ????Address of Provider (Street, City, State, Zip Code) FORMTEXT ?????Name of Physician (If Different than Health Care Provider)Telephone Number FORMTEXT ????? FORMTEXT ???- FORMTEXT ???- FORMTEXT ????Address of Physician (Street, City, State, Zip Code) FORMTEXT ?????Date Blood Collected (mm/dd/yyyy)Blood Collection Type (Check One) FORMTEXT ????? FORMCHECKBOX Venous FORMCHECKBOX CapillaryADDITIONAL INFORMATION TO BE PROVIDED BY THE LABORATORYLaboratory NameClinical Laboratory Improvement Amendment Number FORMTEXT ????? FORMTEXT ?????Address (Street, City, State, Zip Code)Telephone Number FORMTEXT ????? FORMTEXT ???- FORMTEXT ???- FORMTEXT ????Date of Analysis (mm/dd/yyyy)Blood Lead Test Result: FORMTEXT ????? micrograms lead per deciliter of blood FORMTEXT ?????Timetable for ReportingSubmit to:Blood Lead Result (micrograms/deciliter)Report WithinWisconsin Department Of Health ServicesDivision of Public Health45 or more24 hours1 W Wilson Street, Room 1455 – 4448 hoursMadison, WI 53703-26590 – less than 510 daysFax No.: 608-267-0402For more information on adult blood lead test reporting visit , and for childhood blood lead test reporting visit information about electronic reporting, or other questions, email dhsleadpoisoningprevention@. ................
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