Educational Medical Lead Form

Educational Medical Lead Form

This form documents suspected or confirmed lead exposure or elevated blood lead level (BLL) in a student and records parental/guardian instructions, consent for testing/treatment, and authorization to communicate with health care providers and public health authorities as required by law. Information provided is maintained in the student health record and disclosed only as authorized below.

Student Information

Date of Birth:    Student ID:    Grade/Program:

Parent / Guardian Information

Relationship:    Primary Phone:    Email:

Emergency Contact

Phone:    Relationship:

Medical History

Primary Care Provider:    Provider Phone:

Exposure Details

Suspected Source(s) (check all that apply):

Address of suspected exposure (if different from home):

Approximate Date of Exposure / Onset:

Prior Testing / Symptoms

If yes, most recent test date:    Result (BLL): µg/dL    Laboratory:

Consent, Authorization, and Acknowledgements

Consent for blood lead testing and related evaluation: I understand that blood lead testing (fingerstick or venous draw) is a medical test used to determine blood lead level. I authorize the student to receive blood lead testing and/or referral for testing and treatment as indicated by the school nurse or authorized health professional.

Authorization to release information: I authorize release of lead testing results, related medical records, and environmental exposure information to the student's primary care provider, treating clinicians, and public health authorities for the purpose of treatment, case management, environmental investigation, and school health interventions.

Mandatory reporting: I understand that elevated blood lead levels are reportable conditions under public health law and the school is required to notify public health authorities when test results meet reporting criteria.

Liability and treatment authorization: I give permission for school health personnel to take immediate action in the event of a medical emergency related to suspected lead exposure, including arranging transport to an appropriate medical facility. The school and its employees are authorized to share necessary information with medical personnel for emergency care. I certify that the information I have provided is true and accurate to the best of my knowledge.

School Health / Administrative Use Only

Title:    Date Reported:

Laboratory-confirmed BLL (if available): µg/dL    Lab test date:

Certification: By signing below I certify that I am the parent or legal guardian of the student named above (or the student if of legal age). I have read and understand the statements and authorizations on this form. I understand that elevated blood lead levels are reportable and that the school will share results with appropriate health authorities and care providers for treatment and case management.

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