MARYLAND DEPARTMENT OF HEALTH BLOOD LEAD TESTING CERTIFICATE
For a copy of this form in another language, please contact the MDH Environmental Health Helpline at (866) 703-3266.
MDH 4620 Environmental Health Bureau
Revised 07/23 mdh.envhealth@maryland.gov
CHILD’
S NAME: __________________________________________________________________________________
LAST FIRST MI
SEX: MALE ☐ FEMALE ☐ BIRTHDATE: ________________________
MM/DD/YYYY
PARENT/GUARDIAN NAME: _____________________________________ PHONE NO.: _____________________
ADDRESS: __________________________________________ CITY: ________________________ ZIP: __________
Test Date
(mm/dd/yyyy)
Type of Test
(V = venous, C = capillary)
Result
(µg/dL)
Comments
Select a test type.
Select a test type.
Select a test type.
Health care provider or school health professional or designee only: To the best of my knowledge, the blood lead tests
listed above were administered as indicated. (Line 2 is for certification of blood lead tests after the initial signature.)
1. ______________________________ ____________________
Name Title
______________________________ ____________________
Signature Date
2. ______________________________ ____________________
Name Title
______________________________ ____________________
Signature Date
Health care provider: Complete the section below if the child’s parent/guardian refuses to consent to blood lead testing
due to the parent/guardian’s stated bona fide religious beliefs and practices:
Lead Risk Assessment Questionnaire Screening Questions:
Yes☐ No☐ 1. Does the child live in or regularly visits a house/building built before 1978?
Yes☐ No☐ 2. Has the child ever lived outside the United States or recently arrived from a foreign country?
Yes☐ No☐ 3. Does the child have a sibling or housemate/playmate being followed or treated for lead poisoning?
Yes☐ No☐ 4. Does the child frequently put things in his/her mouth such as toys, jewelry, or keys, or eat non-food items (pica)?
Yes☐ No☐ 5. Does the child have contact with an adult whose job or hobby involves exposure to lead?
Yes☐ No☐ 6. Is the child exposed to products from other countries such as cosmetics, health remedies, spices, or foods?
Yes☐ No☐ 7. Is the child exposed to food stored or served in leaded crystal, pottery or pewter, or made using handmade
cookware?
Provider: If any responses are YES, I have counseled the parent/guardian on the risks of lead exposure. ____________
Provider Initial
Parent/Guardian: I am the parent/guardian of the child identified above. Because of my bona fide religious beliefs and
practices, I object to any blood lead testing of my child and understand the potential impact of not testing for lead
exposure as discussed with my child's health care provider.
______________________
___________________________________________ _________________________
Parent/Guardian Signature Date
Clinic/Office Name, Address, Phone
MARYLAND DEPARTMENT OF HEALTH BLOOD LEAD TESTING CERTIFICATE
For a copy of this form in another language, please contact the MDH Environmental Health Helpline at (866) 703-3266.
MDH 4620 Environmental Health Bureau
Revised 07/23 mdh.envhealth@maryland.gov
How To Use This Form
A health care provider may provide the parent/guardian with a copy of the child’s blood lead testing
results from ImmuNet as an alternative to completing this form (COMAR 10.11.04.05(B)).
Maryland requires all children to be tested at the 12 and 24 month well-child visits (at 12-14 and 24-26 months old
respectively), and both test results should be included on this form (see COMAR 10.11.04). If the test at the 12-month
visit was missed, then the results of the test after 24 months of age is sufficient. A child who was not tested at 12 or 24
months should be tested as early as possible.
A parent/guardian and a child’s health care provider should complete this form when enrolling a child in child care, pre-
kindergarten, kindergarten, or first grade. Completed forms should be submitted by the parent/guardian to the
Administrator of a licensed child care, public pre-kindergarten, kindergarten, or first grade program prior to entry. The
child’s health care provider may record the test dates and results directly on this form and certify them by signing or
stamping the signature sections. A school health professional or designee may transcribe onto this form and certify test
dates from any other record that has the authentication of a medical provider, health department, or school. All forms are
kept on file with the child’s school health record.
Frequently Asked Questions
1. Who should be tested for lead?
All children in Maryland should be tested for lead poisoning at 12 and 24 months of age.
2. What is the blood lead reference value, and how is it interpreted?
Maryland follows the CDC blood lead reference value, which is 3.5 micrograms per deciliter (μg/dL). However,
there is no safe level of lead in children.
3. If a capillary test (finger prick or heel prick) shows elevated blood lead levels, is a confirmatory test required?
Yes, if a capillary test shows a blood lead level of ≥3.5 μg/dL, a confirmatory venous sample (blood from a vein) is
needed. The higher the blood lead level is on the initial capillary test, the more urgent it is to get a confirmatory
venous sample. See Table 1 (CDC) for the recommended schedule.
4. What kind of follow-up or case management is required if a child has a blood lead level above the CDC blood
lead reference value?
Providers should refer to the CDC’s Recommended Actions Based on Blood Lead Level
(https://www.cdc.gov/nceh/lead/advisory/acclpp/actions-blls.htm).
5. What programs or resources are available to families with a child with lead exposure?
Maryland and local jurisdictions have programs for families with a child exposed to lead:
• Maryland Home Visiting Services for Children with Lead Poisoning
• Maryland Healthy Homes for Healthy Kids – no-cost program to remove lead from homes
For more information about these and other programs, call the Environmental Health Helpline at (866) 703-3266 or
visit: https://health.maryland.gov/phpa/OEHFP/EH/Pages/Lead.aspx.
Maryland Department of the Environment Center for Childhood Lead Poisoning Prevention:
https://mde.maryland.gov/programs/LAND/LeadPoisoningPrevention/Pages/index.aspx
Families can also contact the Mid-Atlantic Center for Children’s Health & the Environment Pediatric Environmental
Health Specialty Unit – Villanova University, Washington, DC.
Phone: (610) 519-3478 or Toll Free: (833) 362-2243
Website: https://www1.villanova.edu/university/nursing/macche.html
