ONE BOOTH ROAD...
BINGHAMTON, NEW YORK 13905...
(607) 770-1521...FAX 798-7102...(888) 424-LEAD..

LEAD RISK ASSESSMENT QUESTIONAIRE

Childs Name

High Risk Exposure Factors

1) Live in or regularly visit a house with peeling or chipping paint built before 1978? This could include a home of a babysitter or relative, a day care center or preschool, etc.
YES..... NO 		2) Live in or regularly visit a house built before 1978 with planned, recent (within past year) or ongoing renovation or remodeling activity?
YES.....NO
3) Have a brother or sister, a playmate or other household member with a confirmed elevated blood level?
YES.....NO 		4) Live with an adult whose job or hobby involves lead?

YES.....NO
5) Live near an active lead smelter, battery recycling plant or other industry likely to release lead?
YES.....NO 		6) Have a history of possible prenatal exposure (child's mother had elevated blood lead during pregnancy)?
YES.....NO
7) Have iron deficiency or anemia, sickle cell disease, developmental delay or behavioral problems? *
YES.....NO 		8) Have a habit of eating dirt, paint chips, or other non-food items?

YES.....NO
9) Have accessive mouthing habits that are not age appropriate?
YES.....NO 		10) Have an elevated blood lead test 10 ug/dl or higher when last tested?
YES.....NO

A "Yes" answer to any of the above questions indicates High Risk status and blood lead screening should begin at 6 months of age and continue at regular intervals through age 5

A "No" answer to all of the above questions indicates a Low Risk status, however, routine blood lead screening should be done on all children initially at 12 months and again at 24 months of age.

* Note: Children with developmental delays and/or pica behavior continue to be at risk for lead exposure regardless of age and, therefore, routine blood lead screening should continue after age 5.

You May Print Out The Above Form Or...

Click in the Below Boxes and simply send it to us over the net by pressing the "SUBMIT" button. 


         Name    
         Address 
         City    
         State   
         Zip     
         Phone   
         Fax     
         E-Mail