New Jersey Department of Health

Childhood Lead Poisoning Prevention

PO Box 364, Trenton, NJ 08625-0364

REPORT OF CHILDHOOD BLOOD LEAD ANALYSIS BY INDEPENDENT LABORATORY

(For Children 16 Years of Age and Under)

Leave shaded areas blank. Type or print ALL other information on this form. All copies must be legible.	NJDOH Case No.

(Sample ID #):

PATIENT NAME - Last	First	M.I.

Date of Birth (Mo./Day/Yr.)

/ /	Sex

M F
Street Address (NOT P.O. Box)	Apt. No.

Ethnicity

Hispanic (H) Non-Hispanic (NH)
City	State	Zip Code

Race

White (W)	Native American (AI)	Unknown

Black (B)	Asian/Pacific Islander (A)
Patient's Telephone Number

CO/MUN	Medicaid Number

Specimen Type

1Venous

2Capillary	Date of Analysis (Mo./Day/Yr.)

/ /	Analysis Results (in ug/100 mL of whole blood)

Lead __________ ug/dL EP _______________	Testing Method

Rapid Assay

Confirmatory Test
Name of Physician Submitting Specimen

Physician Telephone Number

Physician Office Address

Name of Laboratory Performing Analysis

Laboratory Telephone Number

LP-3

JUL 12	Distribution:	White-NJDOH	Copy-Local Board of Health (Patient's Address)

Copy-Physician Submitting Specimen	Copy-Independent Laboratory

LP-3, Report of Childhood Blood Lead Analysis, by Independent Laboratory

LP-3, blood lead analysis, report, independent lab, laboratory, blood lead,

ewhite

2006-06-14

NJDOH