Lead Risk Assessment Questionnaire

Illinois Department of Public Health

v: 6/4/2019

Printed by Authority of the State of Illinois • P.O.#5519681 6M 3/19 IOCI 19-599
STATE LAW REQUIRES:

All children 6 years of age or younger must be evaluated for lead exposure.

All children must be assessed for risk of lead exposure and tested if necessary for enrollment into daycare, preschool, and kindergarten.
The screens you are filling out will be billed to your insurance. We recommend these screens as they follow the best practice as set forth by the American Academy of Pediatrics
You have the right to decline these screens.

If you decline to fill out this form, please select 'Decline' and continue with the required information.

You have the right to decline these screens.

If you decline to fill out this form, please select 'Decline' and continue with the required information. Decline
Name Name * First Last
Age
DOB DOB * / MM / DD YYYY
Zipcode