Please enter the child's name.
Enter child's current address
Street Address
City
ZIP
If the child has lived at more than one address,
please
enter the PREVIOUS address at which the child lived the longest
?
Street Address
City
ZIP
Enter the child's birthdate
/
(mm/dd/yyyy)
Has this child previously been tested for
BLL?
Yes
No
Don't know
How often does the child use a pacifier?
Never or almost never
Sometimes
Daily or almost daily
Have any of the adults who live with the child ever been
told they had lead poisoning or high blood lead
levels?
Yes
No
Don't know Never
Tested
Have any of the adults who live with the child ever been
told they had lead poisoning or high blood lead
levels?
Yes
No
Don't know Never
Tested
Have any of the child's brothers or sisters ever been told
they had lead poisoning or high blood lead levels
Yes
No Don't
know Never Tested
Has the child ever lived in any house with peeling
paint?
Yes
No
Don't know
Has the child ever lived in any house in which the drinking
water came from lead pipes?
Yes No
Don't know
Last year, how much was the total household income of the
child's family? Please count all sources
What is the child's race? (Please check all that
apply)
What kind of health insurance covers this child?
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