State of Illinois
Illinois Department of Public Health
Childhood Lead Risk Questionnaire
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.
- If responses to all the questions are “NO,” re-evaluate at next age referenced above or more often if deemed necessary.
- If any response is “YES” or “DON’T KNOW,” a blood lead test must be obtained.
- If there are any “YES” or “DON”T KNOW” answers and
- previous blood lead testing was done at 12 and 24 months of age with a result of 4.9 μg/dL or less OR if not performed at 12
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
- there has been no change in address of the child’s home/residential building, child care facility, school, or other frequently
visited facilities and
- risks of exposure to lead have not changed, further blood lead tests are not necessary.
Child’s name: Today’s date:
Age: Birthdate: ZIP Code:
Respond to the following questions by circling the appropriate answer. RESPONSE
- Does this child reside or regularly visit a home/residential building, child-care setting, school or
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)
- Is this child eligible for or enrolled in Medicaid, All Kids, Head Start, WIC, or any HFS medical program?
***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
- Does this child have a sibling with a confirmed blood lead level of 5 μg/dL or higher? ❑ Yes ❑ No ❑ Don’t Know
- In the past year, has this child been exposed to repairs, repainting, or renovation of a building/
home built before 1978?
❑ Yes ❑ No ❑ Don’t Know
- Is this child a refugee, adoptee, or recent visitor of any foreign country? ❑ Yes ❑ No ❑ Don’t Know
- Is this child frequently exposed to imported items (such as, ayurvedic medicine, folk medicines, cosmetics, toys, glazed pottery, spices or other food items, sindoor, or kumkum)?
- Does this child live with someone who has a job or a hobby that may involve lead (for example; jewelry making, building renovation, bridge construction, plumbing, furniture refinishing, work with automobile batteries or radiators, lead solder, leaded glass, bullets, lead fishing sinkers, or recycling facility work)?
- If the child is younger than 12 months of age, did the child’s mother have a past confirmed blood lead level of 5 μg/dL or higher?
- Has the water in your home/residential building, child-care setting, school, or other regularly visited facility been tested and had a confirmed level of lead (5 ppb or higher)?
- Does your child live near an active lead smelter, battery recycling plant, or another industry likely to release lead, or does your child live near a heavily-traveled road where soil and dust may be contaminated with lead?
❑ 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
State of Illinois
Illinois Department of Public Health
Pediatric Lead Poisoning High-Risk ZIP Code Areas
Adams
62301
62320
62324
62325
62338
62339
62346
62347
62348
62349
62351
62359
62360
62365
62376
Alexander
62914
62957
62969
62988
62990
Bond
62086
62246
62262
62273
62275
62284
Boone
61008
61012
61038
Brown
623**
Bureau
613**
Calhoun
62006
62013
62036
62047
62045
62053
62070
Carroll
61014
61046
61051
61053
61074
61078
61285
Cass
626**
Champaign
60949
61801
61802
61815
61816
61820
61821
61843
61845
61849
61851
61852
61859
61862
61863
61866
61871
61872
61875
61877
61878
Christian
62083
625**
Clark
62420
62441
62442
62474
62477
62478
Clay
62434
628**
Clinton
62219
62245
62250
62253
62265
62266
62293
Coles
61912
61920
61931
61938
61943
62440
62469
Cook
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
Crawford
62413
62427
62433
62449
62451
62454
62478
Cumberland
62428
62436
62447
62468
DeKalb
60111
60115
60129
60145
60146
60150
60520
60550
60552
60556
DeWitt
617**
618**
Douglas
61910
61911
61913
61919
61930
61941
61942
61953
61956
DuPage
60101
60106
60126
60137
60181
60185
60187
60519
Edgar
619**
Edwards
62476
62806
62815
62818
62833
Effingham
62411
62414
62426
62445
62461
62467
62473
Fayette
62011
62080
62418
62458
62471
62838
62880
62885
Ford
609**
61773
Franklin
62812
62819
62822
62825
62856
62865
62874
62884
62890
62891
62896
629**
Fulton
614**
615**
Gallatin
62867
62871
62934
62954
62979
62984
Greene
620**
Grundy
60407
60416
60424
60437
60444
60450
60474
60479
Hamilton
62817
62828
62829
62859
Hancock
61450
623**
Hardin
62919
62931
62982
Henderson
614**
Henry
61234
61233
61235
61238
61241
61254
61258
61262
61273
61274
614**
Iroquois
609**
Jackson
62901
62907
62916
62927
62932
62940
62942
62950
62958
62966
Jasper
62432
62434
62448
62459
62475
62480
62481
Jefferson
62810
62814
62846
62864
62872
62883
62898
Jersey
62028
62030
62031
62052
62063
Jo Daviess
61001
61025
61028
61036
61041
61059
61075
61085
61087
Johnson
62908
62912
62923
62939
62967
62972
62985
62995
Kane
60109
60110
60120
60121
60123
60144
60151
60505
60506
60507
Kankakee
60901
60910
60914
60915
60917
60935
60940
60941
60954
60958
60961
60964
60969
Kendall
60536
60541
60650
Knox
61401
61402
61410
61414
61430
61436
61439
61448
61458
61467
61472
61474
61485
61488
61489
61572
Lake
60020
60035
60040
60041
60064
60085
60087
60088
60099
LaSalle
60470
60518
60531
60549
60551
60557
61301
61316
61321
61325
61332
61334
61341
61342
61348
61350
61354
61358
61360
61364
61370
61372
Lawrence
624**
Lee
605**
610**
61310
61318
61324
61331
61353
61367
61378
Livingston
604**
609**
613**
617**
Logan
617**
625**
626**
Macon
61756
62501
62513
62514
6252*
62532
62537
62544
62551
62554
62573
Macoupin
62009
62014
62023
62033
62069
62079
62085
62088
62093
62626
62630
62640
62649
62667
62672
62674
62685
62686
62690
Madison
62001
62002
62018
62021
62024
62040
62048
62058
62060
62061
62084
62087
62090
62095
62097
62234
62281
Marion
62801
62807
62849
62853
62854
62870
62875
62881
62882
62892
62893
Marshall
61369
61375
61377
61424
615**
Mason
615**
626**
Massac
62910
62908
62953
62960
McDonough
614**
623**
McHenry
60033
60034
60180
McLean
61701
61720
61722
61724
61725
61726
61728
61730
61731
61732
61737
61744
61745
61752
61753
61754
61770
61772
61774
61776
Menard
62642
62673
62675
62688
Mercer
612**
614**
Monroe
62244
62248
62279
62295
62298
Montgomery
62015
62017
62019
62032
62049
62051
62056
62075
62076
62077
62089
62091
62094
62533
62538
62560
Morgan
62601
62628
62631
62638
62650
62651
62665
62668
62692
62695
Moultrie
619**
Ogle
60113
61007
61030
61043
61047
61049
61054
61061
61064
61068
61091
Peoria
61451
61517
61523
61526
61529
61533
61536
61539
61552
61559
61562
61569
6160*
61614
61615
61616
Perry
622**
62832
62888
62997
Piatt
61813
61818
61830
61839
61854
61855
61929
61936
Pike
623**
Pope
62928
62938
62947
Pulaski
62941
62956
62963
62964
62970
62976
62992
62996
Putnam
61326
61336
61340
61363
61560
Randolph
62217
62233
62237
62242
62261
62272
62277
62278
62286
62288
62292
62297
63673
Richland
62419
62425
62450
62452
62868
Rock Island
61201
61236
61237
61239
61242
61244
61256
61257
61259
61264
61265
61266
61278
61279
61282
St. Clair
62059
62201
62202
62203
62204
62205
62206
62207
62220
62223
62226
62232
62239
62240
62243
62255
62257
62258
62264
62282
62289
Saline
62917
62930
62935
62946
62965
62977
62987
Sangamon
62515
62520
62530
62539
62558
62561
62615
62625
62661
62670
62689
62693
62701
62702
62703
62704
62707
Schuyler
61452
623**
626**
Scott
626**
Shelby
61957
62422
62431
62438
62444
62462
62463
62465
62534
62553
62565
62571
Stark
614**
Stephenson
610**
Tazewell
61534
61554
61555
61564
61568
61610
61611
61721
61733
61734
61747
61755
61759
Union
62905
62906
62920
62926
62952
62961
62998
Vermilion
609**
61810
61811
61812
61814
61817
61831
61832
61833
61834
61841
61844
61846
61848
61850
61857
61858
61865
61870
61876
61883
Wabash
62410
628**
Warren
614**
Washington
62214
62263
62268
62271
62803
62808
62848
62876
62877
Wayne
62446
62823
62837
62842
62843
62850
62878
62886
62895
White
62820
62821
62827
62835
62844
62861
62862
62869
62887
Whiteside
610**
61230
61243
61250
61251
61252
61261
61270
61277
61283
Will
60408
60410
60417
60421
60432
60433
60434
60435
60436
60468
60481
60484
Williamson
62841
62921
62922
62933
62948
62949
62951
62959
62974
Winnebago
61024
61063
61077
61079
61080
61101
61102
61103
61104
61107
61108
61109
61111
Woodford
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)
State of Illinois
Illinois Department of Public Health
Guidelines for Lead Risk Evaluation
and Blood Lead Testing
- Lead risk evaluation is the use of the Childhood Lead Risk Questionnaire to determine the risk of potential for lead
exposures.
- Blood lead testing is defined as obtaining a blood lead test either by capillary or venous methodology. Only a venous test can serve as a confirmatory blood test.
- A child is considered to have an elevated blood lead level once a venous test is conducted, confirming the blood lead level is ≥5 µg/dL. All capillary (finger/heel stick) test results of ≥5 µg/dL must be confirmed by venous draw. Point of care instruments such as the LeadCare® II cannot be used to confirm an elevated blood lead level, even if the sample is collected by venipuncture.
- It is always appropriate to obtain a diagnostic blood lead test when a child is symptomatic or a potential exposure to
lead has been identified, regardless of child’s age.
- Federal mandates and the Illinois Department of Healthcare and Family Services’ (HFS) policy require that all children enrolled in HFS medical programs be considered at risk for lead poisoning and receive a blood lead test at ages 12 months and 24 months. Children older than the age of 24 months, up to 72 months of age, for whom no record of a previous blood lead test exists, also must receive a blood lead test. All children enrolled in HFS medical programs (such as Medicaid, All Kids, Head Start, and WIC) are expected to receive a blood lead test regardless of where they live. (Consult Handbook for Providers of Healthy Kids Services, Chapter HK-203.3.1, for more blood lead testing and reporting information.)
- Illinois has defined ZIP code areas at high risk for lead exposure based on a variety of considerations, including housing age and poverty rates. Review the list of ZIP codes and determine status of ZIP codes in your area.
Childhood Lead Risk Questionnaire
- 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.
- If responses to all the questions are “NO,” re-evaluate at next age referenced above or more often if deemed necessary.
- If any response is “YES” or “DON’T KNOW,” obtain a blood lead test.
- If there are any “YES” or “DON”T KNOW” answers and
- previous blood lead testing was done at 12 and 24 months of age with a result of 4.9 μg/dL or less OR if not performed at 12 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
- there has been no change in address of the child’s home/residential building, child care facility, school,
or other frequently visited facilities and
- risks of exposure to lead have not changed, further blood lead tests are not necessary.
Illinois Lead Program email: dph.lead@illinois.gov 866-909-3572 or 217-782-3517
TTY (hearing impaired use only) 800-547-0466
