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Run: Lead Risk-Assessment Questionnaire and Provider Statement (Childcare)

This childcare lead risk-assessment questionnaire and provider statement collects lead-testing status, exposure risks, and follow-up actions for children und...

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Submission and Child Identification

Submission Date (required)

Child Initials (required)

Child Date of Birth (required)

Program or Classroom

Primary Contact Email

Consent and Disclosure

I consent to the collection and review of this child's lead-testing and risk-assessment information for childcare compliance and follow-up purposes. (required)

Yes No N/A

I understand this information will be used only for lead-risk assessment, required follow-up, and audit trail purposes. (required)

Yes No N/A

I am authorized to provide this statement on behalf of the child, family, or program. (required)

Yes No N/A

Who is completing this form? (required)

Lead-Testing Status

Has the child been tested for lead? (required)

Date of Most Recent Lead Test

Lead Test Result

Upload test documentation

Optional supporting document such as a lab report or provider letter.

Risk Assessment and Exposure Factors

Is there any known or suspected lead exposure risk? (required)

Possible exposure sources

Describe the exposure concern

Briefly describe only what is needed for follow-up.

Actions already taken to reduce exposure

Follow-Up and Provider Statement

Is follow-up needed? (required)

Recommended follow-up actions

Provider statement

Summarize the child's lead-testing status, risk assessment, and any required next steps.

Provider Name

Acknowledgment and Submission

I confirm the information provided is accurate to the best of my knowledge. (required)

Yes No N/A

Signature (required)

Signature Date (required)

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Email (required)

Your name (optional)

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