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Run: Blood Lead Level Screening Documentation and Tracking Log (Childcare)

Track blood lead screening results for children under 6, document follow-up by lead level, and keep parent communication and consent in one childcare-ready log.

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Child and Screening Identification

Child initials (required)

Use initials or internal identifier if your program does not need full name for this log.

Child date of birth

Collect only if needed to confirm the child is under age 6.

Program or classroom name (required)

Blood lead screening date (required)

Screening source (required)

Blood Lead Test Result

Test type (required)

Blood lead level (µg/dL) (required)

Enter the numeric result only. Use the same units reported by the lab.

Result date

Date the result was reported, if different from the screening date.

Attach lab report or source document

Upload the source document when available for audit trail purposes.

Follow-Up Required by Lead Level

Is follow-up needed? (required)

Follow-up category

Follow-up due date

Follow-up notes

Document referrals, parent notification, retesting plan, or other actions taken.

Communication, Consent, and Tracking

Parent or guardian notified (required)

Notification date

Consent to share information with health provider or public health partner

Only check if the parent or guardian has provided consent to share PII or health information as needed for follow-up.

Yes No N/A

Tracking owner (required)

Name or role of the staff member responsible for the audit trail and follow-up.

Next review date

Date the record should be reviewed for completion of follow-up.

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Email (required)

Your name (optional)

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