Childhood Lead Exposure Questionnaire - Douglas County, NE

1. Is the child less than 36 months old?
   
   
2. Has this child lived in or regularly visited a house located in any of the following Zip Codes during the past two years? This could be their home, daycare, a relative's home, etc. If yes, circle which one? (Douglas County only)
1. 68102
2. 68104
3. 68105
4. 68106
5. 68107
6. 68108
7. 68110
8. 68111
9. 68112
10. 86117
11. 68131
12. 68132
13. 68152
    
    
3. Has this child participated in WIC, food stamps, ADC, Head Start, Medicaid, Kids Connection, OHA or Section 8 housing, or any other public assistance program or free clinic (or is this child in need of assistance or health insurance coverage, but is not covered at this time)? Is this child in foster care?
   
   
4. Does this child live in or regularly visit a house built before 1950? Does the house have a porch where the child spends time?
   
   
5. Does this child live in or regularly visit a house built before 1978 that has been renovated, painted, or remodeled within the last 6 months?
   
   
6. Does this child have any brothers or sisters, housemates, or playmates that have or did have a blood lead level of 10 ug/dL or higher?
   
   
7. Does this child often put things other than food into his or her mouth, such as sucking a thumb or fingers, keys, toys, household items, stones, or dirt? Do they put their mouth on window ledges, furniture, or other objects?
   
   
8. Does this child live with an adult whose job or hobby may involve exposure to lead? (Examples include construction, pottery work, stain glass, soldering, plumbing, auto repair, battery plants, painters, lead smelters, etc.)
   
   
9. Has this child lived or visited for more than a month outside the United States?  Does the child eat candy made in Mexico?
   
   
10. Does the family use a bean pot, pottery, ceramic-ware, or antique dishes for cooking, eating, or drinking?
    
    
11. Has this child ever been tested for lead?

Follow up any previous lead levels ≥10 as recommended by CDC guidelines.

Recommended questionnaire for targeted screening, developed by the Douglas County Health Department Childhood Lead Prevention Program, February 1998.