Illinois Department of Public Health
STATE LAW REQUIRES:
All children 6 years of age or younger must be evaluated for lead exposure.
All children must be assessed for risk of lead exposure and tested if necessary for enrollment into daycare, preschool, and kindergarten.
Complete the Childhood Lead Risk Questionnaire during a well-child or health care visit for children ages 12 and 24 months of age (at minimum) and once a year at annual well-child-visits at ages 3, 4, 5, and 6 years.
and 24 months, a blood lead test was performed at 3, 4, 5, or 6 years of age with a result of
4.9 μg/dL or less, and
visited facilities and
Child’s name: Today’s date:
Age: Birthdate: ZIP Code:
Respond to the following questions by circling the appropriate answer. RESPONSE
other facility built before 1978 or in a high risk ZIP code area? (see reverse side of page for high risk ZIP code area list)
***All Medicaid-eligible children and children enrolled in HFS medical programs shall have a blood lead test at 12 and at 24 months of age. If a Medicaid-eligible child or HFS medical program enrolled child between 36 months and 72 months of age has not been previously tested, a blood lead test shall be performed.
❑ Yes ❑ No ❑ Don’t Know
❑ Yes ❑ No ❑ Don’t Know
home built before 1978?
❑ Yes ❑ No ❑ Don’t Know
❑ Yes ❑ No ❑ Don’t Know
❑ Yes ❑ No ❑ Don’t Know
❑ Yes ❑ No ❑ Don’t Know
❑ Yes ❑ No ❑ Don’t Know
❑ Yes ❑ No ❑ Don’t Know
***ALL blood lead test results MUST be submitted to the Illinois Lead Program.
Fax: 217-557-1188 Phone: 866-909-3572
Signature of Doctor/Nurse Date
Illinois Lead Program 866-909-3572 or 217-782-3517 email: dph.lead@illinois.gov TTY (hearing impaired use only) 800-547-0466
Illinois Department of Public Health
62301
62320
62324
62325
62338
62339
62346
62347
62348
62349
62351
62359
62360
62365
62376
62914
62957
62969
62988
62990
62086
62246
62262
62273
62275
62284
61008
61012
61038
623**
613**
62006
62013
62036
62047
62045
62053
62070
61014
61046
61051
61053
61074
61078
61285
626**
60949
61801
61802
61815
61816
61820
61821
61843
61845
61849
61851
61852
61859
61862
61863
61866
61871
61872
61875
61877
61878
62083
625**
62420
62441
62442
62474
62477
62478
62434
628**
62219
62245
62250
62253
62265
62266
62293
61912
61920
61931
61938
61943
62440
62469
60008
60016
60018
60022
60025
60029
60043
60053
60056
60068
60070
60074
60076
60077
60091
60093
60104
60130
60131
60153
60154
60155
60160
60162
60163
60164
60165
60169
60171
60173
60176
60195
602**
603**
60402
60406
60409
60411
60415
60419
60422
60425
60426
60428
60429
60430
60438
60445
60453
60455
60456
60457
60458
60459
60466
60469
60472
60473
60475
60476
60482
60501
60513
60525
60526
60534
60546
60558
606**
60701
60706
60707
60712
60714
60803
60804
60805
60827
62413
62427
62433
62449
62451
62454
62478
62428
62436
62447
62468
60111
60115
60129
60145
60146
60150
60520
60550
60552
60556
617**
618**
61910
61911
61913
61919
61930
61941
61942
61953
61956
60101
60106
60126
60137
60181
60185
60187
60519
619**
62476
62806
62815
62818
62833
62411
62414
62426
62445
62461
62467
62473
62011
62080
62418
62458
62471
62838
62880
62885
609**
61773
62812
62819
62822
62825
62856
62865
62874
62884
62890
62891
62896
629**
614**
615**
62867
62871
62934
62954
62979
62984
620**
60407
60416
60424
60437
60444
60450
60474
60479
62817
62828
62829
62859
61450
623**
62919
62931
62982
614**
61234
61233
61235
61238
61241
61254
61258
61262
61273
61274
614**
609**
62901
62907
62916
62927
62932
62940
62942
62950
62958
62966
62432
62434
62448
62459
62475
62480
62481
62810
62814
62846
62864
62872
62883
62898
62028
62030
62031
62052
62063
61001
61025
61028
61036
61041
61059
61075
61085
61087
62908
62912
62923
62939
62967
62972
62985
62995
60109
60110
60120
60121
60123
60144
60151
60505
60506
60507
60901
60910
60914
60915
60917
60935
60940
60941
60954
60958
60961
60964
60969
60536
60541
60650
61401
61402
61410
61414
61430
61436
61439
61448
61458
61467
61472
61474
61485
61488
61489
61572
60020
60035
60040
60041
60064
60085
60087
60088
60099
60470
60518
60531
60549
60551
60557
61301
61316
61321
61325
61332
61334
61341
61342
61348
61350
61354
61358
61360
61364
61370
61372
624**
605**
610**
61310
61318
61324
61331
61353
61367
61378
604**
609**
613**
617**
617**
625**
626**
61756
62501
62513
62514
6252*
62532
62537
62544
62551
62554
62573
62009
62014
62023
62033
62069
62079
62085
62088
62093
62626
62630
62640
62649
62667
62672
62674
62685
62686
62690
62001
62002
62018
62021
62024
62040
62048
62058
62060
62061
62084
62087
62090
62095
62097
62234
62281
62801
62807
62849
62853
62854
62870
62875
62881
62882
62892
62893
61369
61375
61377
61424
615**
615**
626**
62910
62908
62953
62960
614**
623**
60033
60034
60180
61701
61720
61722
61724
61725
61726
61728
61730
61731
61732
61737
61744
61745
61752
61753
61754
61770
61772
61774
61776
62642
62673
62675
62688
612**
614**
62244
62248
62279
62295
62298
62015
62017
62019
62032
62049
62051
62056
62075
62076
62077
62089
62091
62094
62533
62538
62560
62601
62628
62631
62638
62650
62651
62665
62668
62692
62695
619**
60113
61007
61030
61043
61047
61049
61054
61061
61064
61068
61091
61451
61517
61523
61526
61529
61533
61536
61539
61552
61559
61562
61569
6160*
61614
61615
61616
622**
62832
62888
62997
61813
61818
61830
61839
61854
61855
61929
61936
623**
62928
62938
62947
62941
62956
62963
62964
62970
62976
62992
62996
61326
61336
61340
61363
61560
62217
62233
62237
62242
62261
62272
62277
62278
62286
62288
62292
62297
63673
62419
62425
62450
62452
62868
61201
61236
61237
61239
61242
61244
61256
61257
61259
61264
61265
61266
61278
61279
61282
62059
62201
62202
62203
62204
62205
62206
62207
62220
62223
62226
62232
62239
62240
62243
62255
62257
62258
62264
62282
62289
62917
62930
62935
62946
62965
62977
62987
62515
62520
62530
62539
62558
62561
62615
62625
62661
62670
62689
62693
62701
62702
62703
62704
62707
61452
623**
626**
626**
61957
62422
62431
62438
62444
62462
62463
62465
62534
62553
62565
62571
614**
610**
61534
61554
61555
61564
61568
61610
61611
61721
61733
61734
61747
61755
61759
62905
62906
62920
62926
62952
62961
62998
609**
61810
61811
61812
61814
61817
61831
61832
61833
61834
61841
61844
61846
61848
61850
61857
61858
61865
61870
61876
61883
62410
628**
614**
62214
62263
62268
62271
62803
62808
62848
62876
62877
62446
62823
62837
62842
62843
62850
62878
62886
62895
62820
62821
62827
62835
62844
62861
62862
62869
62887
610**
61230
61243
61250
61251
61252
61261
61270
61277
61283
60408
60410
60417
60421
60432
60433
60434
60435
60436
60468
60481
60484
62841
62921
62922
62933
62948
62949
62951
62959
62974
61024
61063
61077
61079
61080
61101
61102
61103
61104
61107
61108
61109
61111
61516
61530
61545
61561
61570
61738
61760
61771
IDPH - Revised April 2023
1. Former high-risk ZIP Codes remained high risk (666); 2. Low to high-risk ZIP codes based on model Risk Index Score ≥15 (228); 3. Low to high-risk ZIP codes based on lead prevalence ≥7.5 at Risk Index Score <15 for ≥5 children tested with lead level ≥3.5 μg/dL% (118); 4. P.O. Box in the middle of high-risk areas (19)
Illinois Department of Public Health
and Blood Lead Testing
exposures.
lead has been identified, regardless of child’s age.
Childhood Lead Risk Questionnaire
24 months of age (at minimum) and once a year at annual well-child-visits at ages 3, 4, 5, and 6 years.
or other frequently visited facilities and
Illinois Lead Program email: dph.lead@illinois.gov 866-909-3572 or 217-782-3517
TTY (hearing impaired use only) 800-547-0466