Appendix A

Latest version.

DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN

Division of Public Health Childhood Lead Poisoning Prevention Program

BEH 7142(3/00)

BLOOD LEAD LAB REPORTING FORM

Information to be provided by the Health Care Provider

(Physician, Nurse, Hospital Administrator, Local Health Officer, Director of Blood Drawing Site) - See PDF for table

If test results indicate 45 or more micrograms lead per 100 milliliters of blood, send this form immediately by fax to 608-267-0402. Return all forms to: Terri Dolphin, DHS-Division of Public Health, P. O. BOX 2659, Madison, WI 53701-2659.

                    
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