APPENDIX A
DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN
Division of Public Health Childhood Lead Poisoning Prevention Program
BEH 7142(3/00)
BLOOD LEAD LAB REPORTING FORM
Information to be provided by the Health Care Provider
(Physician, Nurse, Hospital Administrator, Local Health Officer, Director of Blood Drawing Site)
If test results indicate 45 or more micrograms lead per 100 milliliters of blood, send this form immediately by fax to 608-267-0402. Return all forms to: Terri Dolphin, DHS-Division of Public Health, P. O. BOX 2659, Madison, WI 53701-2659.
