Blood Lead Level Report

Provider Report of Point-of-Care Blood Lead Level Results

Use this online form to submit all blood level test results for Alabama residents that are not submited via electronic laboratory report. Contacts for other state programs may be found here: https://www.cdc.gov/nceh/lead/programs/default.htm.

All required fields are marked with a red asterisk (*); it is not possible to submit the report without completing all required fields.

**Per ADPH Administrative Code 420-4-1, blood lead results are a notifiable condition in Alabama; therefore, all blood lead results should be reported to the Alabama Childhood Lead Poisoning Prevention Program (ALCPPP).

If you have questions about this form or the information required, please contact the ACLPPP at (334) 206-3883 or FHSLeadFax@adph.state.al.us.

Date of Report:

M-D-Y

Reportable Disease/Health Condition:

* must provide value

Patient's First Name:

* must provide value

Patient's Last Name:

* must provide value

Patient's Medicaid ID:
(If applicable)

Patient's Date of Birth:

* must provide value

M-D-Y

Patient's Age (in years):

View equation

Patient's Sex:

* must provide value

Patient's Race:

* must provide value

White

Black or African American

Asian

American Indian or Alaskan Native

Native Hawaiian or Other Pacific Islander

Other

Unknown

If patient's race is other, please specify:

Patient's Ethnicity:

* must provide value

Patient's Street Address of Residence:

* must provide value

Patient's City of Residence:

* must provide value

Patient's State of Residence:
(ONLY use this form to report results for Alabama residents. Contacts for other state programs may be found here: https://www.cdc.gov/nceh/lead/programs/default.htm.)

* must provide value

Patient's County of Residence:

* must provide value

Patient's Zip Code of Residence:

* must provide value

Blood Drawn Date:

* must provide value

M-D-Y

Sample Type:

* must provide value

Detection:

* must provide value

Result:

* must provide value

If patient <18 years old, provide parent/proxy's name:

* must provide value

Patient's Phone Number:

* must provide value

Provider's First Name:

* must provide value

Provider's Last Name:

* must provide value

Provider's Institution Name:

* must provide value

Provider's Phone Number:

* must provide value

Provider's email:

Provider's Street Address:

* must provide value

Provider's City:

* must provide value

Provider's State:

* must provide value

Provider's Zip Code:

* must provide value

NOTE:
Please do not use ampersands (& symbol) or carriage returns (i.e. pressing the enter button to start a new paragraph) when entering into this field.

Comments:

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Verify Information

Before submitting the REPORT Card, please review the summary below and verify it is accurate. If everything is correct, click the submit button below. Patient name, state, and county are required fields.

If you would like to print this disease/event report prior to submission, click Ctrl plus P on your keyboard.

You will be able to download a pdf of the report after submission.

Date of Submission	______
Disease/Condition	______
Reporter	______ ______, ______, ______
Patient	______ ______ (DOB: ______) / ______, ______
Blood Lead Level	______ ______ µg/dL

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