Childhood Lead Exposure Risk Questionnaire -Douglas County NE

Name of Child_________________________________ DOB_____________________

1a.   Is the child less than 36 months old? Yes   No   Unknown

1.      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) Yes   No   Unknown

68102   68104   68105   68106

68107   68108   68110   68111

68112   68117   68131   68132   68152

2.      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?  Yes   No   Unknown

3.      Does this child live in or regularly visit a house built before 1950? Does the house have a porch where the child spends time?  Yes   No   Unknown

4.      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?  Yes   No   Unknown

5.      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?  Yes   No   Unknown

6.      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?  Yes   No   Unknown

7.      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.)  Yes   No   Unknown

8.      Has this child lived or visited for more than a month outside the United States?  Does the child eat candy made in Mexico? Yes   No   Unknown

9.      Does the family use a bean pot, pottery, ceramic-ware, or antique dishes for cooking, eating, or drinking?  Yes   No   Unknown

10.    Has this child ever been tested for lead?  Yes   No   Unknown

When _______________ Where __________________ Result___________

Any Yes or Unknown answer (other than #10) should generate a blood lead test for this child if no testing done within prior 9-12 months.  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.

Updated 11/27/01