ALABAMA DEPARTMENT of PUBLIC HEALTH
 
ABLES Investigation Response Form

Adult Blood Lead Epidemiology and Surveillance (ABLES)
Elevated Blood Lead Investigation Response Form

Please complete the following information for patients with blood lead levels >=10 micrograms/deciliter paying special attention to occupational exposure and potentially exposed children in the home.

* ABLES Patient ID

* Patient First Name

* Patient Last Name

* Patient Date of Birth (DOB)

Patient Sex

Male Female

Patient Ethnicity

Hispanic Not Hispanic Unknown

Patient Race (Select all that apply)

White/Caucasian  
Black/African American  
Asian  
American Indian/Alaskan Native  
Hawaiian/Pacific Islander  
Other:

Patient Home Address

Patient City

Patient County of Residence


Patient State

Patient Zip

Home Phone (xxx-xxx-xxxx)

Alternate Phone (xxx-xxx-xxxx)

* Does the patient have children (<21 years) living in the home?

Yes No Unknown

* Occupation (e.g., mechanic, welder, unknown)

Company Address

* Company Name (e.g., business name, self-employed, unknown)

Company City

Company County


Company State

Company Zip

Reason For Testing

Symptomatic  
Employer Screening  
Patient Request  
Other:

* Date Sample Collected

Blood Lead Level (micrograms/deciliter)

Ordering Physician

Testing Laboratory

* Form Completed By (i.e., Your Name)

Date Form Completed

Position of Person Completing Form

Phone Number of Person Completing Form (xxx-xxx-xxxx)




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