New Jersey Department of Health

Consumer, Environmental and Occupational Health Service

PO Box 369

Trenton, NJ 08625-0369

(609) 826-4984

CLINICAL LABORATORY REPORT OF ELEVATED LEVELS OF HEAVY METALS:

LEAD: IN ADULTS (Greater than 16 Years of Age)

ARSENIC, CADMIUM, MERCURY: IN PERSONS OF ANY AGE

Instructions to Lab:

Complete report, as required by N.J.A.C. 8:44-2.11, should be forwarded immediately to the New Jersey Department of Health (NJDOH) at the above address or fax to (609) 292-5677. Laboratory must obtain all information from physician before submitting report to NJDOH.

REPORTED INDIVIDUAL
1. Name of Individual (Print)	2. Date of Birth

(First)	(MI)	(Last)
3. Street Address

4. Age (If DOB Unavailable)

5. City

State

Zip Code

6. Home Telephone Number

( )
7. Sex

Male Female	8. Race

White	Am. Ind./ Alaskan Native	Other

Black	Asian/Pacific Islander	9. Hispanic Origin

Yes No Unknown
10. Name of Employer

11. Telephone No. of Employer

( )
12. Address of Employer

City

State

Zip Code

13. Occupation

PHYSICIAN
14. Last Name of Requesting Physician

First Name

M.I.

15. Telephone No. of Physician

( )
16. Address of Physician

City

State

Zip Code

17. Name of Medical Facility of Requesting Physician

LABORATORY
18. Name of Testing Laboratory

19. Telephone No. of Laboratory

( )
20. Address of Laboratory

City

State

Zip Code

21. Date Sample Taken	22. Date Sample Analyzed
/ /
/ /
Month/Day/Year	Month/Day/Year
LABORATORY RESULTS
Sample Type	ARSENIC	CADMIUM	LEAD	MERCURY
Reportable Level	Value

(With Unit)	Reportable Level	Value

(With Unit)	Reportable Level	Value

(With Unit)	Reportable Level	Value

(With Unit)
BLOOD	> .07 µg/mL	> 5 µg/L Whole Blood	All Blood

Test Results	> 2.8 µg/dL
URINE	> 100 µg/L	> 3 µg/gram creatinine	> 80 µg/L	> 20 µg/L

OCC-34

JUL 12

OCC-34, Clinical Laboratory Report of Elevated Levels of Heavy Metals: Lead: In Adults (Greater than 16 Years of Age); Arsenic, Cadmium, Mercury: In Persons of Any Age

elevated levels of heavy metals, cadmium, lead, arsenic, mercury, occupational health, clinical laboratory report, OCC-34, OCC,

EWhite

2004-09-23

NJDOH