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S2AY Network Lead ManualLast Revision: May 17, 2016

PH Committee Approved Revision June 20, 2017SECTION 1 Background

Childhood lead poisoning is a preventable, serious environmental health problem. Lead exposure is recognized as one of the most common environmental toxins for young children. The primary way in which most children are exposed to harmful levels of lead is through contact with deteriorating lead paint and lead contaminated dust. The typical hand-to-mouth activity of young children provides the pathway for lead to enter the body.

In most cases, children are exposed to lead by ingesting lead paint chips or dust contaminated by deteriorating lead paint. Interior dust can become contaminated with lead as the result of chipped or peeling paint in older dwellings (pre-1978 housing), friction caused by opening and closing windows with lead paint, or through the disturbance of lead paint during preparation of paint surfaces for repainting, paint removal, or remodeling. Less commonly, secondary sources such as water contaminated by its flow through lead pipes or brass fixtures, soil contaminated by lead dust, and certain consumer products that contain lead can be significant contributory sources. Other sources contributing to lead poisoning can include lead-glazed ceramic ware, certain ethnic spices, foods and cosmetics (see Appendix 1 for Ethnic Spices, Herbs, and Cosmetics Containing Lead).

People in certain occupations such as painters, plumbers, mechanics, or construction workers may come into contact with lead on the job and bring it home on their skin and clothes. Hobbies that use lead, such as making pottery or stained glass, refinishing furniture, making lead figurines, using indoor/outdoor firing ranges or loading homemade ammunitions can also be a source of exposure for children (Appendix 1 for Sources of Lead).

Young children’s systems absorb lead more efficiently than those of adults. Some of the protective mechanisms that are well developed in adults are immature in young children, thereby making them more vulnerable to the effects of some toxic chemicals. Increased lead levels or chronic exposure can have long-lasting effects on children, families and communities. Exposure to even small amounts of lead can contribute to behavior problems, learning disabilities, and lowered intelligence. While lead poisoning prevention efforts primarily target young children under age six years, harmful effects are associated with exposure to lead at any age.

Exposure to lead is associated with a range of serious health effects on young children. Lead is a systemic toxin that affects virtually all body systems. Lead exposure has been associated with anemia, hearing loss, diminished skeletal growth and delayed pubertal development, dental caries, hypertension, osteoporosis, pregnancy complications and low birth weight. Lead exposure is an important cause of preventable brain injury and neurodevelopmental dysfunction that is associated with detrimental effects on children’s cognitive and behavioral development, including measurable declines in IQ. Although there is no established threshold for the harmful effects of lead, the federal Centers for Disease Control and Prevention (CDC) has defined a BLL of greater than or equal to 5 mcg/dL as the definition of lead poisoning (elevated blood lead level, or “EBLL”) and the action level for public health intervention.

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PH Committee Approved Revision June 20, 2017

SECTION 2 Roles and Responsibilities of Lead Program Staff

Local Health Department Lead Program Staff is defined in the annual Lead Poisoning Prevention Program (LPPP) work plan that is submitted to NYSDOH.

The roles and responsibilities of the Local Health Department’s (LHD) Lead Program Staff regarding identification and coordination of follow-up services for children with elevated blood lead levels (EBLLs) are defined in New York Codes, Rules and Regulations (NYCRR) Title 10 Subpart 67-1. As defined in 67-1.6, local health departments shall: Provide blood lead screening or arrange for blood lead screening for each child who requires

screening and whose parent or guardian is unable to obtain a lead test for their child because the child is uninsured or the child's insurance does not cover lead screening.

Establish a sliding fee schedule for blood lead screening of children from families with incomes in excess of 200% of the federal poverty level, pursuant to Section 606 of the Public Health Law, and collect fees for blood lead testing from third party payers, when available.

Provide environmental management for children with confirmed blood lead levels (BLLs) > 15 mcg/dL. (Note: On May 6, 2009, the NYS Code of Rule and Regulations Part 67-1 was revised to lower the blood lead level requiring environmental management and other specified follow-up services from 20 to 15 mcg/dL, and to clarify that follow-up services are required for all children aged birth to 18 years with elevated blood lead levels. These changes became effective on June 20, 2009.)

Provide data to identify exposure patterns and high risk populations for strategic planning for lead poisoning prevention at the state and local levels.

Institute measures to identify and track children with elevated blood lead levels (EBLLs) to assure appropriate follow-up.

LHD Program Staff responsibilities for case identification and tracking of follow up services are performed with the use of the New York State Department of Health’s (NYSDOH) LeadWeb system or other approved systems. All blood lead test results are currently reported to the NYSDOH by laboratories certified to conduct lead testing. The enacted 2009-2010 State Budget authorized changes to Public Health Law 1370 and 2168 regarding collection, store and access of any authorized lead data in the Department’s New York State Immunization Information System (NYSIIS). The NYSDOH has developed a process that allows physician office laboratories (POLs) to submit reports for blood lead tests on children less than eighteen years of age electronically through the New York State Immunization Information System (NYSIIS).

Blood lead test results for all children aged birth up to 18 years are uploaded daily into LeadWeb for download by the appropriate Local Health Department (LHD) Lead Program staff. As specified in the annual Lead Poisoning Prevention Program (LPPP) work plan activities, LHDs are required to pre-screen and match all records in LeadWeb to assure timely and appropriate follow-up for children with elevated blood lead levels. The matching process assures that

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children with blood lead test results are assigned to the appropriate county where they reside. This also ensures that all children tested in a county in a given year are included in the annual surveillance data for that county. Directions for pre-screening and matching are located in the Nursing Tutorial found in Lead Web or Section 5 of this manual. The Lead Program Coordinator/Designee is responsible to ensure all Work Plan activities are performed.

NYS LHD lead programs are responsible for tracking all children with BLLs > 10 mcg/dL to assure that appropriate follow-up services are provided. Current New York State regulations define “follow-up” as actions by LHDs and health care providers which, depending on the child’s blood lead level and exposure history, include as appropriate.

Confirmatory and follow-up blood lead testing; Risk reduction education; Nutritional counseling; Diagnostic evaluation which includes a detailed lead exposure assessment, a

nutritional assessment including iron status, and developmental screening; Medical treatment, if necessary; Environmental management; and Case management.

To meet their responsibilities, LHD lead programs work in coordination with other team members, who may include the child’s parent(s) or guardian(s), the child’s health care provider(s), other LHD program staff and LHD or NYSDOH District Office (DO) environmental health staff, and other health professionals as needed. Details regarding specific follow-up services required at different blood lead levels are described in Section 5 of this document. In addition, a complete summary of the roles and responsibilities of health care providers for lead testing and follow-up of children is included in Appendix 6 – Public Health Law.

LHD lead programs do not have to directly provide all follow-up services, but are responsible for tracking and documenting that required interventions have occurred. This can be accomplished either by documenting appropriate follow-up by health care providers (HCPs), by directly providing the necessary follow-up services, or by a combination of the two. In instances when a LHD serves as the primary care provider for a child, the LHD is responsible for directly providing required follow-up services. Establishing collaborative working relationships with HCPs is essential for effective case coordination at the local level. This type of cooperative approach is needed in order to assure that all follow-up activities are completed to decrease the child’s BLL, and to correct lead hazards in the child’s environment.

LHD programs also make referrals through LeadWeb or other currently approved local data systems to LHDs or NYSDOH District Office (DO) environmental health programs for environmental management of all children with BLLs > 15 mcg/dL. Communication and collaboration between lead program staff and LHD or NYSDOH DO environmental staff is necessary for effective coordination of services for children with elevated blood lead levels who require environmental management.

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PH Committee Approved Revision June 20, 2017The goal of follow-up for children with EBLLs is to coordinate the services required to reduce children’s BLLs below 10 mcg/dL, and to identify and reduce potential sources of lead exposure in children’s environments to prevent further lead exposure. LHD program staff responsible for case coordination must have appropriate training and experience and function within the scope of their professional responsibilities and training.

The Bureau of Occupational Health (BOH) routinely contacts parents and caregivers of adolescents age 16 and 17 with BLLs > 10 mcg/dL through telephone interviews. When an adolescent 16 or 17 years of age is identified with an elevated BLL, the LHD should first consult with the NYSDOH BOH (518-402-7900) to discuss results of the BOH assessment to avoid duplication of efforts and to determine the need for additional follow up. The LHD should work collaboratively with BOH to identify, reduce or eliminate exposure sources as part of their overall case coordination responsibilities.

For any child (regardless of age) identified through the Lead Program or environmental assessments as having potential work related lead exposure, the LHD or NYSDOH District Office can consult with the Bureau of Occupational Health and the Occupational Health Clinics located throughout the State to identify, reduce or eliminate exposure sources.

The NYS Bureau of Occupational Health is also a resource for pregnant women with elevated blood lead levels. The LHD will refer all pregnant women with elevated blood lead levels to the NYS Bureau of Occupational Health (See Section 7 of this manual for guidance).

Confidentiality of all Lead records must be maintained. Consent from a child’s parent or guardian or from the patient for adults must be obtained for any referrals other than for referrals to the medical community and NYSDOH. See S2AY Network Administrative Manual – Release of Information and Confidentiality of Protected Health Information Policy.

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SECTION 3 Risk Assessment Screening and Blood Lead Level Screening

SCREENING:

Screening activities are to be conducted in accordance with the current NYSDOH policies and regulations pertaining to the Lead Poisoning Prevention Program. Screening activities will also adhere to the agency’s policies regarding informed consent and confidentiality. The sites at which the Local Health Department may perform screening/testing include:

o Well Child Clinic, if applicableo Immunization Clinics or in-home immunization visitso WIC Clinicso By appointment/walk in office visitso Home visits to identified families with high risk of lead exposureo Additional community sites as deemed appropriateo Children may also be referred to local laboratory for testing.

RISK QUESTIONNAIRE SCREENING: At minimum all children, ages 6 months to 6 years, and children referred to the LHD as

refugees at 6 years through 16 years attending immunization clinic or lead screening clinic will be annually assessed for lead risks using the Lead Pre-Screening Questionnaire (see Appendix 2 for Pre-Screening Questionnaire and Consent Form). This questionnaire may be administered more frequently, such as at each clinic visit. Lead poisoning prevention education will also be provided.

BLOOD LEAD LEVEL SCREENING:Local Health Department (LHD) will provide or arrange for blood lead level screening for all children 6 months – 6 years and refugee children 6 months of age through 16 years. Who requires BLL screening based on:

o Risk factor questionnaire results ORo Need for testing at ages one and two years (check Leadweb or the NYS Immunization

Information System (NYSIIS) for previous screenings) ORo Children in lead case management ORo Refugee children 6 months of age through 16 years not previously tested ORo Child has NOT been previously tested.

AND

Whose parent or guardian is unable to obtain a blood lead test for their child because the child is:

o Uninsured ORo Underinsured (insurance will not cover lead screening) ORo Without a primary care provider ORo At the request of a parent or legal guardian

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If it is determined, that an uninsured or underinsured child should be BLL screened and the parent consents to screening, one of two scenarios are possible (see Appendix 2 for Pre-Screening Questionnaire and Consent Form):

o Screening via finger stick using the Lead Care II performed by Public Health Nurses (See Lead Care II Policy in the S2AY Network Equipment and Supply Manual) or by capillary fingerstick and sent to Wadsworth Laboratory (see Appendix 3 for Protocol for Collecting Sample for Submission to Wadsworth).

OR

o Screening via venipuncture using the laboratory requisition slip or obtaining the specimen and sending it to Wadsworth (see Agency-specific policy for venipuncture procedure).

In either scenario, uninsured or underinsured families will be informed of the sliding fee scale for BLL screening (See Appendix 4 for County sliding fee scale). If payment is required by the family, family will complete the agency specific paperwork to document transaction (see Appendix 4 for County sliding fee scales). If payment is made by family, provide receipt.

NOTE: No child will be denied lead screening due to inability to pay the sliding fee scale.

Insured families requesting BLL testing via the Lead Care II analyzer will provide their insurance information on the Lead Care II consent form (see Appendix 2). For individuals with private insurance, the Lead Care II testing will be based on the County sliding fee scale. Insured families requesting BLL testing via venipuncture laboratory requisition slip will be encouraged to seek testing through their primary care provider. If the family does not have a primary care provider, the lead lab requisition slip can be given using the sliding fee scale, if applicable, and the family will be assisted in obtaining a PCP. If applicable, LHD may elect to offer venipuncture lab test.

At the time a lead screen is done, the parent/guardian shall receive both written and verbal information about lead poisoning prevention. This information is to include possible sources, effects, nutrition, and risk reduction measures.

For those children who present to Public Health for a lead test who are uninsured, Public Health staff will discuss the Navigator Program to assist with applying for health insurance.

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PH Committee Approved Revision June 20, 2017Children 6 months – 72 months

Lead Risk Assessment Questionnaire should be done at each child visit orat least annually for children six months to six years of age.

Questionnaire results determined to be:

At Risk OR Not at Risk and are up-to-date Due for one or two year testing OR with age appropriate testing Children at least 12 months of age who have NOT been previously tested

Provide anticipatory Provide anticipatory guidance onguidance on Lead Poisoning Prevention Lead Poisoning Prevention

Encourage lead screening by:Fingerstick (Lead Care II) OR Venipuncture Recommend re-risk screen at least

annually and retesting as age appropriate.

Refer to PCP or Refer to PCP orPerform Lead Care II, if applicable Uninsured/No PCP - Sliding fee to& if parent consents: provide lab requisition or draw specimen Un/underinsured use sliding fee scale Insured – gather insurance information

Provide information

about blood lead testingProvide and explainBlood Lead Results

Follow-up of elevated blood levels in accordance with accepted medical standards & public health guidelines

NOTE: All elevated fingerstick testing requires confirmatory venous test: Laboratory finger stick samples are considered elevated at or above 10 mcg/dL Lead Care II finger stick samples are considered elevated at or above 5 mcg/dLThe time frame for venous testing is dependent on the level of elevation. (See Section 5 of this manual.)

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PH Committee Approved Revision June 20, 2017SECTION 4 Blood Lead Level (BLL) Reporting

Lead Care II AnalyzerAll children receiving finger stick lead levels via the Lead Care II Analyzer will have results reported to the NYSDOH

PROCEDURE: Obtain Lead Test Results according to Lead Care II Blood Lead Testing Policy and

Procedure

Until approved to report electronically via ECLRS the New York State Department of Health Lead Test Report (# DOH 4430) [see appendix 5 for County-specific Lead Test Report Form #4430]) must be completed.

Enter all information completely and legibly. Required information is marked with an asterisk (*) and the remaining fields are strongly recommended to facilitate timely and accurate follow-up and surveillance activities.

NOTE: Date of Report equals date report sent to the State. Each County has their own CLIA (Clinical Laboratory Improvement

Amendments) Each County has been issued a PFI number from the State.

Complete the sample accession number using the following format: First four positions are your PFI number. Next eight positions are the date the sample is collected, (written as mmddyyyy), and the last two positions are an incrementing number beginning with 01 each day. For example, if your PFI is 9999 and you conducted lead tests for five patients on September 8, 2009 then the first accession number for this day is 99990908200901. An accession number will be automatically generated when reporting via ECLRS.

Test Results: Lead Care II results range from 3.3 mcg/dL to 65 mcg/dL and are displayed to one decimal

place.

Low results or any value below 3.3 mcg/dL should be reported as < 3.3.

High results or any value greater than 65 mcg/dL should be reported as > 65.

Values within the range of 3.3 to 65 mcg/dL must be reported to NYSDOH as numeric results.

Blood lead test results greater than or equal to 5 mcg/dL generated by CLIA-waived devices, such as Lead Care II, must be confirmed with an appropriately collected venous sample, analyzed by a clinical laboratory that holds a NYS permit in toxicology- blood lead using another test method. The level of 5 mcg/dL has been established by the NYSDOH to maximize the identification of children with lead poisoning. This level is consistent with

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the manufacturer’s recommendation for the use of a Lead Care II device to minimize possible false negatives.

Fax the test results to the child’s primary care provider, if known.

Questions related to NYSDOH reporting guidelines may be directed to NYSDOH Lead Program at 518-402-7600 (phone)

Copy of the Lead Test Report will be filed per agency specific protocol.

If you have any questions regarding blood lead testing, follow-up or reporting, contact NYSDOH Lead Program.

Lead Test Results Received Via Paper CopyIf the LHD receives lead test results submitted via paper copy by the laboratory, Lead Program Staff will look at the LeadWeb Manual for guidance with entering the result on LeadWeb.

Lead Results Received Via TelephoneIf a lead result is received from a provider via telephone, request fax confirmation. Do not enter the result in LeadWeb prior to electronic result being available through LeadWeb. Case management can begin and should be documented outside of LeadWeb. Once LeadWeb is available, notes may be entered into LeadWeb.

Resolution of Laboratory issuesIf a Laboratory fails to report an elevated lead level in a timely manner or if there are other laboratory issues noted the following steps will be taken:

Lead program staff will contact the laboratory and attempt to resolve the issue directly with them.

Lead Program staff may contact the Lead regional representative to inform them of the issue if needed.

If the issue is still not resolved, then Lead Program staff will contact the NYSDOH Central office to report the issue and the steps that have already been taken to resolve the issue.

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SECTION 5 Coordination of Follow-up Services for Children

Appropriate and timely educational, medical and environmental interventions will be provided to all children with elevated blood lead levels in accordance with Public Health Law Part 67 of Subchapter G of Chapter II of Title 10. (See Appendix 6 for copy of Public Health Law.)

Lead Poisoning Prevention Program staff shall: Prescreen information in LeadWeb on a daily basis during normal work hours and match

LeadWeb records with results of 10 ug/dL or greater daily, and all records less than 10 ug/dL at least weekly (see Nursing Tutorial on LeadWeb). Review prior seven days of records to identify if any records may have been transferred to the County, entered as a paper lab slip or electronically loaded for a previous day and need to be processed. Records should not remain in the holding bin for more than one week. LHD will enter all blood test results received by other means into LeadWeb if necessary.

Forward a copy of the results to child’s primary care provider if the lead screen was done by LHD.

Confidentially refer siblings and children less than 6 years of age who frequent the home of a lead poisoned child with a blood lead level of 10 mcg/dL or greater for lead testing.

Based on the child’s blood lead level, the follow-up procedures are as follows:

Confirming Elevated Capillary Lead Tests Elevated capillary blood lead level results must be confirmed by venous blood samples. The

timeframe for confirming elevated capillary blood tests is based on the level obtained. The higher the BLL on the capillary screening test, the more urgent is the need for confirmatory venous testing so that appropriate follow-up services can be initiated.

Local Health Department will initiate contact with the parent/guardian within 72 hours of receipt of lab results. Contact may be made by phone and/or letter to inform them of the need for confirmatory venous testing per tables below (see Appendix 7 for county-specific letter regarding need for confirmatory testing).

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o Lead Care II capillary blood lead test results > 5 mcg/dL require confirmatory venous blood sample.

Table 1 summarizes the schedule for obtaining confirmatory venous samples when initial capillary sample was obtained via Lead Care II. Table 1. Timeframe for Confirming Elevated Capillary Lead Tests Using Lead Care II Analyzer.

Perform confirmatory venous analysis within:5-14 mcg/dL Confirm lead level within 1-3 months15-44 mcg/dL Confirm lead level within 1 week – 4 weeks*45 or greater mcg/dL Confirm lead level within 48 hours

*The higher the BLL on the screening test, the more urgent the need for confirmatory testing.Magellan Diagnostics LeadCare II User’s Guide

o Laboratory tested, capillary blood lead test results > 10 mcg/dL require confirmatory venous blood sample.

Table 2 summarizes the schedule for obtaining confirmatory venous samples when initial capillary sample results are elevated, based on CDC guidelines. Confirmatory testing should be performed in accordance with the timeframes noted in Table 2. Table 2. Timeframe for Confirming Elevated Capillary Lead TestsCapillary blood lead level (BLL) Perform confirmatory venous analysis within:>5-9 mcg/dL Confirm lead level within 1-3 months**10-44 mcg/dL Confirm lead level within 1 week – 1 month*45-59 mcg/dL Confirm lead level within 48 hours60-69 mcg/dL Confirm lead level within 24 hours> 70 mcg/dL Confirm lead level immediately as an emergency test

*The higher the BLL on the screening test, the more urgent the need for confirmatory testing.Adapted from Table 3.3 Recommended Schedule for Obtaining a Confirmatory Venous Sample; CDC Managing Elevated Blood Lead Levels Among Young Children: Recommendations fromthe Advisory Committee on Childhood Lead Poisoning Prevention. Atlanta: CDC; 2002.**CDC Response to Advisory Committee on Childhood Lead Poisoning Prevention Recommendations in “Low Level Lead Exposure Harms Children: A Renewed Call of Primary Prevention” CDC, June 7, 2012.

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Follow-up on Venous or Capillary Blood Lead Tests 5 mcg/dL to 9.9 mcg/dL Upon the daily LeadWeb check, the lead coordinator/designee will identify children with blood lead levels between 5 to 9.9 mcg/dL. The individual LeadWeb record of these children will be queried to determine:

1. Is the child currently receiving case management services? 2. Has the child received case management services in the past? 3. Does the child require a confirmatory test?

If the above three questions are NO, the parents of the child will be sent the 5 to 9.9mcg/dL letter encouraging a repeat blood lead test in three to six months per physician recommendation (see Appendix 7 of this manual). The letter will be cc’d to the child’s provider if known. A copy of the New York State Department of Health “What Your Child’s Blood Lead Test Means” must be sent with this letter. It is expected that this effort will identify, in a more timely fashion, children whose BLL may be increasing.

Follow-up on Confirmed Venous Blood Lead TestsIdeally, you want to act as quickly as possible with any elevated blood lead test results. Consult with Regional Lead Poisoning Prevention Center as needed (see Appendix 8 – Contact Information for Regional Lead Poisoning Prevention Resource Centers).

Table 3. Follow-up Actions Based on Confirmed Venous Blood Lead Levels Children Aged Birth to Less Than Eighteen Years

Confirmed Blood Lead Level (BLL)

Timeframe for Action Follow-up Actions

10-14 mcg/dL Preferably within 5 working days but no later than 20 working days of BLL confirmation

Lead Coordinator/Designee will: Contact parent by letter (see Appendix 7 for county-

specific parent letter regarding BLL of 10-14 mcg/dL) and/or by telephone.Provide the following:o risk reduction educationo nutritional counselingo information regarding possible lead sourceso date when next venous blood lead test is due

Notify physician by letter or telephone regarding patient’s elevated blood lead level status and recommendation for follow-up testing.

Monitor that follow-up testing has been performed in accordance with follow-up testing schedule in Table 4.

Document all actions in LeadWeb within 10 working days.

If repeat testing has not been performed within 4 to 5 months, contact parent and physician by telephone and/or letter to emphasize benefits of repeat testing.

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PH Committee Approved Revision June 20, 201715-19 mcg/dL Preferably within 5

working days but no later than 10 working days of BLL confirmation

Lead Coordinator/Designee will: Contact parent by telephone to schedule home visit.

Refer to Environmental Sanitarian as soon as possible but no longer than 1-2 business days of receipt of venous blood lead level greater than 15 mcg/dL via LeadWeb. The environmental investigation must be initiated within 10 working days of receipt of referral (see Appendix 13 for Protocol for Referral to Environmental Health).

During the home visit, education/information will be provided and will include:o Patient bill of rights; Agency privacy

statement; consent for treatment, payment and healthcare operations, including confidentiality, and release of information (see Administrative Manual: Evaluation, Admission and Discharge Policy).

o Possible sources of lead exposureo Risk reduction measureso Housekeeping interventionso Hygieneo Nutrition, including hemoglobin / hematocrito Complete Home Visit Report (see Appendix 9)o Complete 24-Hour Dietary Recall (see

Appendix 10)o Complete developmental assessment using age

appropriate Ages and Stages Questionnaire (See Appendix 11 for guidance regarding Development Screening)

o Start the Lead Program File Summary Sheet (see Appendix 12)

o Date and importance of next venous blood lead test

o Refer as appropriate to DSS, WIC, Child Find, local housing assistance program(s) and/or Regional Lead Poisoning Prevention Center. Parent/Guardian consent must be obtained for any referrals other than to the medical community and NYS DOH District Office (DO). Release of Information Policy and Procedure in the S2AY Administrative Manual.

Send physician letter notifying regarding patient’s elevated blood lead level, admission to case management (see Appendix 7 for County-specific Letter to MD), copy of home visit report, contact information for Regional Lead Resource Center and

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PH Committee Approved Revision June 20, 2017recommendation for follow-up testing.

Coordinate and communicate with primary care providers to ensure each child receives the appropriate follow-up as indicated. See Table 4 below.

Educate parent/guardian regarding recommendation to obtain a medical evaluation of the child by the primary care provider.

Document all actions in LeadWeb within 10 working days (see LeadWeb Nursing Tutorial)

If repeat testing has not been performed within 3 to 4 months, contact parent and physician by telephone and/or letter to emphasize importance of repeat testing.

20-44 mcg/dL Within 5 working days of BLL confirmation

Perform all actions for BLLs 15-19 mcg/dL, plus Call Environmental Sanitarian to ensure receipt of

referral. The environmental investigation by the LHD

Environmental Department or DO must be initiated within 5 working days of receipt of referral.

45-69 mcg/dL Within 48 hours of BLL confirmation

Perform all actions for BLLs 20-44 mcg/dL, plus: Refer to Environmental Sanitarian immediately upon

receipt of venous blood lead level greater than 45 mcg/dL via LeadWeb and telephone. The environmental investigation by the LHD Environmental Department or DO must be initiated within 48 hours of receipt of referral.

Contact the child’s primary care provider to initiate medical treatment (chelation).

Communication with health care provider and family to assure treatment is planned. Provide contact information and facilitate consultation with the Regional Lead Resource Center.

If admitted to the hospital for chelation, hospital discharge must not occur until a lead-safe environment is located for the child. If the child is not hospitalized, a lead-safe environment is required during chelation therapy (see temporary relocation of lead poisoned children on page 16).

Communication with the health care provider and Regional Lead Resource Center to assure appropriate follow-up.

Post-chelation follow up including blood lead level monitoring in accordance with discharge instructions (usually within 7-21 days after treatment).

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PH Committee Approved Revision June 20, 2017 Report elevated BLL to the NYSDOH Lead Program

Regional Representative Document all actions in LeadWeb within 5 working

days (see LeadWeb Nursing Tutorial)

70 mcg/dL or greater

Within 24 hours of BLL confirmation

Perform all actions for BLLs 45-69 mcg/dL, plus: Immediate hospitalization for inpatient chelation

treatment. Initiation of environmental investigation by LHD

Environmental Department or DO within 24 of blood lead confirmation.

Document all actions in LeadWeb within 5 working days (see LeadWeb Nursing Tutorial)

Table 4. Follow-up Blood Lead Testing Schedule for Children

Venous Blood Lead Level Early Follow-up Testing Late Follow-up Testing (first 2-4 tests after identification) (after BLL begins to decline)>5-9 mcg/dL 3 months 6-9 months10-19 mcg/dL 1-3 months 3-6 months20-24 mcg/dL 1-3 months 1-3 months25-44 mcg/dL 2 weeks -1 month 1 month> 45 mcg/dL As soon as possible Chelation with subsequent follow-up

Adapted from Table 3.4 Recommended Schedule for Follow-Up Blood Lead Testing; CDC Managing Elevated Blood Lead Levels Among Children: Recommendations from the Advisory Committee onChildhood Lead Poisoning Prevention. Atlanta: CDC; 2002.

CDC Response to Advisory Committee on Childhood Lead Poisoning Prevention Recommendations in “Low Level Lead Exposure Harms Children: A Renewed Call of Primary Prevention” CDC, June 7, 2012.

Additional Considerations: LHD program staff may recommend to Health Care Providers that confirmatory or follow-up

blood lead testing be done sooner if assessments or other circumstances warrant earlier testing. However, confirmatory and follow-up testing should not exceed timeframes specified in Tables 1 and 2 respectively.

Seasonal variation of BLLs may necessitate more frequent follow-up testing during the summer months to assure BLLs are not rising rapidly.

HCPs may choose to repeat blood lead tests within one month on patients newly identified with EBLLs or for children less than 12 months of age to assure BLLs are not rising rapidly.

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PH Committee Approved Revision June 20, 2017Environmental Referral

Environmental Referral and Follow up DocumentationThe table below provides the contact information for environmental services including home investigations for lead.

CountyContact Information –Environmental Services Phone and Email

Chemung Tom Kump, Director of Environmental Services

607-737-2019Email: [email protected]

Livingston Mark Grove, Director of Environmental Health

585-243-7280Email: [email protected]

Ontario NYSDOH Geneva District Office Phone: 315-789-3030

Schuyler NYSDOH Hornell District Office Phone: 607-324-8371

Seneca Seneca County Health DepartmentPrincipal Sanitarian

Phone: (315) 539-1947

Steuben NYSDOH Hornell District Office Phone: 607-324-8371

Wayne NYSDOH Geneva District Office Phone: 315-789-3030

Yates NYSDOH Geneva District Office Phone: 315-789-3030

See Appendix 13 Protocol for Lead Web Environmental Referral > 15. In addition to the LeadWeb referral, a phone call should be made to the LHD environmental services contact to notify them of the referral. This should then be documented in LeadWeb under child notes and on the back of the Home Investigation Form in the child’s hard copy chart. The Environmental Sanitarian may attempt to schedule the home visit at the same time as the nurse.

The Lead Program Coordinator will follow up with the environmental sanitarian to make sure that LHD receives copies of the home inspections, progress of renovations, and clearance of the properties that received notices of order and demand. These reports will all be placed in the child’s hard copy chart.

Temporary relocation of lead poisoned childrenIf a family with children needs to be temporary relocated due to an elevated lead level or because of the abatement process the LHD staff will work with the following resources:

Other Family Members American Red Cross County DSS Church Groups Other support/resources identified on a case by case basis

All attempts will be made to work with the family to have the best possible outcome for the children.

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mailto:[email protected]




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Modified Protocol for Follow-up of Children Age Six to Eighteen Years with Elevated Blood Lead Levels

While lead poisoning prevention efforts primarily target children under age six years, who are most vulnerable to lead poisoning with elevated lead levels that typically peak in early childhood, adverse effects are associated with exposure to lead at any age.1 Elevated blood lead levels (EBLLs) in early childhood (i.e., measurements of average or peak blood lead levels) have a continuing negative association with measures of cognitive impairment later in childhood.2 Moreover, a recent scientific study suggests that blood lead levels (BLLs) measured closest to the time of neurodevelopmental testing (i.e. concurrent BLLs) have the strongest association with measures of neurodevelopmental impairment, even when conducted for children age six years and older.2

Although neither universal nor routine risk-assessment based blood lead testing is required or recommended for children age six years and older, HCPs may choose to test children of any age for blood lead. Whenever new cases of EBLLs are identified among children of any age (birth to 18 years), HCPs and local health departments (LHDs) must provide and coordinate follow-up services in accordance with New York State Public Health Law and regulations and current medical standards and public health guidelines. In addition, children who are initially identified at younger ages with EBLLs that persist beyond the age of six years must continue to be followed until medical or other established criteria for discharge from follow-up services are met (see section 3-C of NYSDOH Guidelines for Follow-up of Children with Elevated Blood Lead Levels for Local Health Department’s Lead Poisoning Prevention Program, August, 2009).

Requirements for follow-up services for children with EBLLs are outlined in NYCRR, Title X, Section 67-1.2(a) and in section 3-A and 3-B of NYSDOH Guidelines for Follow-up of Children with Elevated Blood Lead Levels for Local Health Department’s Lead Poisoning Prevention Program, August, 2009. (Note: On May 6, 2009, revisions to New York Code of Rules and Regulations were adopted clarifying that follow-up services are required for all children with EBLLs up to age 18 years.)

In general, children over age six years with EBLLs require the same components of follow-up services as younger children, including follow-up blood lead testing, risk reduction education, nutritional counseling, developmental screening, environmental management, and medical

1 Centers for Disease Control and Prevention (2007). Interpreting and managing blood lead levels < 10 mcg/dL/dL in children and reducing childhood exposures to lead: recommendations of CDC’s Advisory Committee on Childhood Lead Poisoning Prevention.

2 Chen A., Dietrich K.N, Radcliffe J. & Rogan, W.J. (2005). IQ and blood lead from 2 to 7 years of age: are the effects in older children the residual of high blood concentrations in 2-year olds? Environmental Health Prospectives, 113(5): 597-601.

2

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PH Committee Approved Revision June 20, 2017treatment, depending on blood lead levels. However, children over age six years may frequently have different exposure sources and different needs for follow-up services that are dependent on case-specific assessments.

In order to fulfill responsibilities for coordination of follow-up services for children age six to eighteen years with EBLLs, LHDs may:

1. follow the same processes and protocols that they utilize for children under age six years, or

2. choose to utilize a modified approach to tailor follow-up services to the specific and unique needs of individual older children. The protocol in Section D of the NYSDOH Guidelines for Follow-up of Children with Elevated Blood Lead Levels for Local Health Department’s Lead Poisoning Prevention Program, August, 2009 outlines a modified approach that LHDs may use to tailor the coordination of follow-up services for children newly identified with EBLLs between the ages of six and 18 years.

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SECTION 6 Discharge Criteria From Lead Case Management

DISCHARGE FROM FOLLOW-UP SERVICES CRITERIA

LHD staff work with the child’s Health Care Provider (HCP) and parent(s) or guardian(s) to assure that all required follow-up activities have been completed consistent with the child’s BLL. Certain circumstances (described below) may occur which necessitate the discharge of the child from active case follow-up by the LHD. In all such instances, the LHD is required to provide written notification to the child’s HCP, parent(s) or guardian(s) and other agencies involved in the care of the child (see Appendix 7 for County-specific Discharge from Case Management MD Letter). The LHD should also discuss the need for appropriate long-term developmental follow-up with the HCP and the child’s parent(s) or guardian(s). Documentation of discharge from follow-up services needs to be recorded in the child’s record and LeadWeb or other currently-approved local databases.

A. The below Child Status definitions in LeadWeb are automatically assigned based on the child’s blood lead test history. These may not be changed. Please contact the Lead Poisoning Prevention Program with any questions.

Active-Confirmed:Child with confirmed elevated blood lead levels (i.e. initial venous elevated, or elevated fingerstick followed by an elevated venous, or two consecutive elevated fingersticks within 84 days).

Pending-Needs Confirmation:Child with an initial elevated fingerstick (or unknown sample type) blood lead level that requires venous confirmation.

False Elevated:Child with an initial elevated fingerstick blood lead level, but a test confirmed that it was not elevated.

Never Elevated:Child’s blood lead level(s) are all reported as less than 10 mcg/dL.

Unassigned – Needs Retest:Child had an initial blood lead test drawn, but the sample was unable to be processed for analysis, and no child status assigned.

B. Local Health Departments (LHDs) are able to update a child status category in the following circumstances when the child and/or family meet the criteria specified in the corresponding definitions:

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Medical dischargeTo be eligible for medical discharge from follow-up services, a child with a previous confirmed EBLL must have at least two consecutive blood lead levels (either venous or capillary) < 15 mcg/dL taken at least six months apart or at least one BLL < 10 mcg/dL, and all required follow-up activities, including environmental management, must have been completed consistent with the child’s BLL, as outlined in Tables 3 and 4 above. Discharge of a child from follow up services should be based upon joint nursing and environmental decision making. The decision for discharge should be based upon the child’s BLL and whether there are any outstanding environmental violations that warrant continued follow up of the child. If the child is no longer spending time in an environment where hazards were previously cited and the child’s BLL meets the discharge criteria, a decision to close the case from follow up services can be made. A letter should be sent to the child’s health care provider and to the parents(s) or guardians(s) that all follow-up services have been completed. A copy of this letter should be included in the child's paper record. The LHD should change the LeadWeb child status to Medical Discharge. A child less than six years of age discharged from follow-up services should continue to receive routine lead testing at required ages, i.e. testing of all children at or around ages one and two years, and annual risk assessment, with blood lead testing for children identified at risk for lead exposure, for children up to age six years.

Refusal of ServiceThe child may be discharged if the parent(s) or guardian(s) refuses services offered by the LHD after three attempts have been made to educate the family concerning these services, and the health and developmental risks associated with an EBLL. At least three documented attempts to contact the parent(s) or guardian(s) must have failed to consider case closure on this basis. A certified return receipt letter must be included as, at least one, of the attempts. Documentation of these attempts needs to be included in the child’s record. Contact with the child’s HCP to discuss the parent refusal of services must be completed prior to closure and documented in the child’s record. A letter should be sent to the child’s HCP to notify them of the parent(s) or guardian(s) refusal of services. A copy of this letter should be included in the child’s record. For a child with an EBLL > 15 mcg/dL, the LHD may want to consider contacting Child Protective Services (CPS) prior to any consideration of closing the case.

Lost to Follow-upThe county may be unable to contact a family, and so a child may be lost to follow-up. This may occur for a variety of reasons, and may be considered if a child has missed two consecutive appointments for follow-up testing or home visits. Contact efforts should be documented in the child’s record.

At least three documented attempts by phone or letter to contact the parent(s) or guardian(s) must have failed to consider discharge on this basis. A certified return receipt letter is recommended as one of the attempts. The LHD needs to contact the child’s HCP office to see if a new address or phone information for the family is available. This contact must be completed prior to discharge. Documentation of all attempts needs to be included in the child’s record. The LHD should change the LeadWeb child case status to Lost to Follow-up.

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Relocated Out of StateIf a child with an EBLL moves to another state and the LHD is aware of this move, the LHD should contact the lead program at the state Health Department in the state where the child has moved. Select the child surveillance status “Relocated out of State.” State CLPPPs are available on the CDC web site: http://www.cdc.gov/HealthyHomes/programs.html

ExpiredChild has died.

C. Local Health Departments are required to electronically transfer a child’s complete record to another locality when they become aware a child has relocated.

TransferThe transfer should be completed in LeadWeb by selecting the Transfer link to the right of the Child Surveillance Status. This will generate an automatic e-mail alerting the new LHD of the transfer. LHDs can add the child’s new address in the comment section of the email. A phone call to the new LHD is recommended when a child with a confirmed elevated blood level is transferred and follow up activities are in progress. When the record is transferred, please do not change the child surveillance status.

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http://www.cdc.gov/HealthyHomes/programs.html



SECTION 7 Lead Poisoning Prevention in Pregnancy

The LHD will encourage all prenatal care providers to follow the recommendations from the Centers for Disease Control and Prevention and the American Colleges of Obstetricians and Gynecologists.

The Centers for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynecologists (ACOG) do not recommend blood lead testing of all pregnant women in the United States. Obstetric health care providers should consider the possibility of lead exposure in individual pregnant women by evaluating risk factors (See Box 1 below) for exposure as part of a comprehensive health risk assessment and perform blood lead testing if a single risk factor is identified. Assessment of lead exposure should take place at the earliest contact with the pregnant patient (ACOG Committee Opinion, August 2012).

Prenatal Care Providers will be encouraged to refer all pregnant women with a BLL of ≥ 5 mcg/dL to the Regional Lead Resource Center and / or the New York State Bureau of Occupational Health (See appendix 8). Follow-up BLL testing will be performed as appropriate based upon risk factors and/or BLL result from the first test.

The LHD will consider additional referrals to promote positive pregnancy outcomes, including local Medicaid services, WIC, and other community services.

LHD staff working with the Bureau of Occupational Health, Regional Lead Resource Center, Prenatal Care Provider, and Pediatrician will ensure appropriate blood lead testing for the newborn following delivery.

Box 1. Risk Factors for Lead Exposure in Pregnant and Lactating Women

Recent emigration from or residency in areas where ambient lead contamination is high—women from countries where leaded gasoline is still being used (or was recently phased out) or where industrial emissions are not well controlled.

Living near a point source of lead—examples include lead mines, smelters, or battery recycling plants (even if the establishment is closed).

Working with lead or living with someone who does—women who work in or who have family members who work in an industry that uses lead (eg, lead production, battery manufacturing, paint manufacturing, ship building, ammunition production, or plastic manufacturing).

Using lead-glazed ceramic pottery—women who cook, store, or serve food in lead-glazed ceramic pottery made in a traditional process and usually imported by individuals outside the normal commercial channels.

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Eating nonfood substances (pica)—women who eat or mouth nonfood items that may be contaminated with lead, such as soil or lead-glazed ceramic pottery.

Using alternative or complementary substances, herbs, or therapies—women who use imported home remedies or certain therapeutic herbs traditionally used by East Indian, Indian, Middle Eastern, West Asian, and Hispanic cultures that may be contaminated with lead.

Using imported cosmetics or certain food products—women who use imported cosmetics, such as kohl or surma or certain imported foods or spices that may be contaminated with lead.

Engaging in certain high-risk hobbies or recreational activities—women who engage in high-risk activities (eg, stained glass production or pottery making with certain leaded glazes and paints) or have family members who do.

Renovating or remodeling older homes without lead hazard controls in place—women who have been disturbing lead paint, creating lead dust, or both or have been spending time in such a home environment.

Consumption of lead-contaminated drinking water—women whose homes have leaded pipes or source lines with lead.

Having a history of previous lead exposure or evidence of elevated body burden of lead—women who may have high body burdens of lead from past exposure, particularly those who have deficiencies in certain key nutrients (calcium or iron).

Living with someone identified with an elevated lead level—women who may have exposure in common with a child, close friend, or other relative living in the same environment.

Modified from Centers for Disease Control and Prevention. Guidelines for the identification and management of lead exposure in pregnant and lactating women. Atlanta (GA): CDC; 2010. Available at: http://www.cdc.gov/nceh/lead/publications/leadandpregnancy2010.pdf.

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http://www.cdc.gov/nceh/lead/publications/leadandpregnancy2010.pdf



SECTION 8 Education/Outreach

EDUCATION

The Local Health Department staff shall actively work to ensure that the county’s health and human service groups are kept apprised of current and accurate information regarding the Lead Poisoning Prevention Program, CDC Guidelines and Legislation as applies to Lead Poisoning. (See Appendix 14 – Local Health Department Lead Poisoning Prevention Program staff by county) These service groups may include but not be limited to:

o Pediatricians, family practitioners and obstetricianso Public health nurseso Hospital emergency room personnelo Day care centers and family day care providerso Nursery school and preschool programso Department of Social Serviceso Elementary school personnelo Women, Infants & Children (WIC)/Expanded Family Nutrition Education Program

(EFNEP)o Local housing assistance program(s)o School Nurseso OB/GYN, Midwives

Educational and in-service programs may be offered. Information may include the following:

o their role and responsibility according to CDC Guidelines and Public Health Lawo the role of the local health departmento available resources for children with elevated lead levelso available printed materials and videos for purchase, loan or free of chargeo hazards of leado need for blood lead testingo signs and symptoms of lead toxicity and its sequelaeo proper nutrition o housekeeping interventions

See Appendix 15: Lead Anticipatory Guidance and NYS Order For Educational Material.

OUTREACH

COMMUNITY HEALTH ASSESSMENT

The community health assessment process should be used to target high-risk populations in the local community. These may include but are not limited to:

areas/pockets of poverty24


PH Committee Approved Revision June 20, 2017 areas of old and/or substandard housing areas of heavy traffic areas of industrial pollution specific populations:

o Amish/Mennoniteso racial and ethnic minoritieso migrantso developmentally delayedo occupational hazardo gun hobbyists

The community health assessment process should be an on-going process.

OUTREACH TO AT-RISK COMMUNITY AND TARGET POPULATIONS

The Lead Poisoning Prevention Program will conduct/promote professional and public health education to increase public knowledge about lead poisoning and its prevention in children and pregnant women. Program staff will provide/promote activities with primary prevention that result in, identifying and controlling potential lead hazards before a child is poisoned. Possible avenues might include:

Community Service Agencies:o WICo Health Centers/Hospitalso Local Department of Social Serviceso Day Care Centers, Family Day Care Providers, and Headstarto Early Intervention Programso Rural Health Networkso Public and private housing-related organizations

Section 8 Provider Code Enforcement Realtors Contractors Do-It-Yourself Home Centers Landlords DSS Other Human Service agencies

Health Care Providerso Primary Care Providerso Obstetricianso Midwiveso Nurse Practitioners

Volunteer Agencies:o Service clubs (Kiwanis, Lions, VFW, Rotary, etc.)o Red Crosso Churches

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PH Committee Approved Revision June 20, 2017o Senior Citizens Groups

Media:o Local Health Department websiteo Radio and local newspaperso Community agency newsletters and community calendaro Distribution of flyers and posters to local businesses

Community Events:o local fairs/festivals/carnivals

Worksite:o health/wellness fairs

Parents/Guardians of 1 and 2 year old childreno Letter to 1 year old children in the County encouraging testing at 12 months of

age (see Appendix 7 for county-specific Outreach Letter).o Letter to 2 year old children in the County encouraging testing at 24 months of

age (see Appendix 7 for county-specific Outreach Letter).SECTION 9 Program Evaluation

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PH Committee Approved Revision June 20, 2017REPORTINGThe Lead Poisoning Prevention Program Staff shall utilize the LeadWeb application for Lead Tracking and Environmental Reduction to manage and track screening and follow-up of children. Quarterly DOH reports and voucher will be generated per Lead Program workplan requirements for:

First quarter Oct 1 – Dec 31Second quarter Jan 1 – Mar 31Third quarter Apr 1 – Jun 30Fourth quarter Jul 1 – Sep 30

The Lead Poisoning Prevention Program Staff shall complete an annual workplan and budget as required as part of the contract renewal process. Workplan, budget and quarterly report templates will be provided by NYSDOH.

Lead Program staff may partner with LHD Immunization staff to schedule and conduct regular record reviews at County physician offices and/or through LEADWeb/NYSIIS to determine compliance with lead and immunization regulations, and to provide education and support. If using LEADWeb to conduct record reviews, search for children through the lab search query not the child search query to capture out-of-county children associated with the practice.

See next page for guidance on AFIX Guidance.

Quality Assurance

See S2AY Network Administration Manual: Performance Management/Quality Assurance (PMQI) Plan Policy, including Lead chart audit tool.

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AFIX GuidanceThe Lead Poisoning Prevention Coordinator may conduct regular record reviews at County physician offices (and/or through NYSIIS) to determine compliance with lead regulations, and to provide education and support. These visits are known as AFIX visits (Assessment, Feedback, Incentives, and exchange of information). As an alternative to AFIX visits, The Lead Poisoning Prevention Coordinator may choose to provide lead testing reports from NYSIIS for 1 and 2 year olds.

The cohort of children for review is determined by the Immunization Action Plan. At present, the cohort includes children 19 to 35 months of age, as of the assessment date. These children are assessed for blood lead screening at both the ages of one year and two years.

When determining which children should be included in the one and two year old cohort the following definitions are used:

Completion of One Year Old lead testing is defined as any child who received a Blood Lead Level between the ages of 9 months and less than 18 months.

Completion of Two Year Old lead testing is defined as any child who received a Blood Lead Level between the ages of 18 months to less than 36 months. For the purpose of this analysis, children less than 28 months of age who did not yet receive a two year old test are not included in the results. While children less than 28 months of age who did receive a test are included in the results.

The immunization coordinator will provide a list of children to be included in the blood lead test review. This list also identifies the child’s date of birth. The lead coordinator will search NYSIIS to query lead testing results.

Upon completion of the query, the results will be compiled for discussion with and distribution to the Primary Care Provider/Office Staff. This information is provided in-person during the post assessment site visit. The post assessment site visit also provides an opportunity for the lead poisoning prevention coordinator to discuss the effects of lead poisoning, the importance of lead testing, and methods to increase testing (if applicable).

See sample format for provider letter below. Directions on how to create the excel graph are also provided below.

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At Age One At Age Two0

10

20

30

40

50

2919

18

12

Lead Testing at ABC PracticeTested Not Tested

Tested/Not Tested by Age

Num

ber o

f Chi

ldre

n

The graph above shows the lead testing rates as obtained through LeadWeb and NYSIIS for children 19-35 months of age as of (insert the assessment date) from the (insert provider practice name). In total, (insert # of records reviewed) from children born in (insert year of birth range) were audited. This audit took place in (insert Month and Year).

One Year Old Testing Rates: A total of 47 children were eligible for the one year old lead testing defined as testing

between the ages of 9 month to less than 18 months of age: 29 Children (61.7%) received testing at or around one years of age 18 Children (38.3%) did not receive testing at or around one years of age

Two Year Old Testing Rates: A total of 31 Children were eligible for two year old testing defined as testing between

the ages of 18 to less than 36 months of age. For the purpose of this analysis, children less than 28 months of age who did not yet receive a two year old test were not included in the results. 19 Children (61.3%) received testing at or around two years of age 12 Children (38.7%) did not receive testing at or around two years of age

Of the 2010-2011 cohort, the lead testing rates for the number of children attending ABC Practice (27 – 35 months of age) who received two blood lead tests (One test at or around age one year and a second test at or around age two) by age 36 Month was 55.2%

16 out of 28 children received a lead test at or around one year and at or around two years of age

In 2009, the lead testing rate for the number of children who received two or more blood lead screening test by age 36 month (birth cohort 2006) was:

50.1% for New York State 46.6% for Ontario County

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Depending on the version of Excel you are working with, follow the procedure below or the procedure that begins on page 36.

Directions to create the Excel Graph are as follows:

Open up Excel Set up chart as below inputting the number of children tested and not tested by age

category.

At Age One At Age TwoTested 10 5Not Tested 5 2

Using your computer curser, highlight area as below:


Click INSERT at the top of the screen

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Under Charts, Click the down arrow at Column, a list of available column charts will appear. Click 2D Stacked Column (2nd Choice under 2D column).

A basic graph will appear.

31



To format this basic graph, you must click somewhere on the graph area. Once you click on the graph area, Chart Tools will appear as an option:

Next Click Layout:

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PH Committee Approved Revision June 20, 2017 LAYOUT opens the following options:

o Chart Title- (Choose “Above Chart”) “Lead Testing at ABC Practice”o Axis Title

Horizontal (Choose “Title Below Axis”)- Tested/Not Tested by Age Vertical (Choose “Rotated Title) – Number of Children

o Legend (Choose “Show at Top”)o Data Labels (Choose “Center”)

The graph you created now looks like this.


10121416

105

5

2



Num

ber o

f Chi

ldre

n

To make a Bolder Box around the graph, select Format in chart tools

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PH Committee Approved Revision June 20, 2017and ABC


10

20

30

40

50

2919

18

12



Num

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f Chi

ldre

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This graph can now be copied and pasted into a word document. Add your description (as in the sample above) and you have completed the summary or audit results.

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Alternate instructions for creating a graph in Excel

Open up Excel Set up chart as below inputting the number of children tested and not tested by age

category.


Using your computer curser, highlight area as below:


Click INSERT at the top of the screen

35


PH Committee Approved Revision June 20, 2017 On the tool bar, Click the down arrow at this chart symbol and a list of available

column charts will appear. Click 2D Stacked Column (It’s the middle chart option).

A basic graph will appear.

36


PH Committee Approved Revision June 20, 2017 To format this basic graph, you must click somewhere on the graph area. Once you click

on the graph area, on the left hand side click on Add Chart Element

This drops down to several options: follow belowo Chart Title- (Choose “Above Chart”) Click in the Title Box and write in “Lead

Testing at _______________”o Axis Title

Choose Primary Horizontal, click on the box on the chart that says Axis Title and type in Tested/Not Tested by Age

Choose Primary Vertical, click on the box on the chart that says Axis Tille and type in Number of Children

o Legend- Choose Topo Data Labels Choose “Center

The graph you created now looks like this.


10121416

105

5

2



Num

ber o

f Chi

ldre

n

37


PH Committee Approved Revision June 20, 2017 To make a Bolder Box around the graph, Click on the outside of the graph box to

highlight it. select Format in chart tools and click on what color ABC (box) you want.

This graph can now be copied and pasted into a word document. Click on the graph to get the box highlighted. Once your mouse turns into a compass arrow, right click your mouse. Choose copy and then paste this onto your word document. Add your description (as in the sample above) and you have completed the summary or audit results. Appendix 1

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PH Committee Approved Revision June 20, 2017Appendix 1


PH Committee Approved Revision June 20, 2017Appendix 1

Sources of Lead Lead paint –lead-based paint found in many homes built before 1978 have lead-based paint.

Lead paint that is deteriorating can be a source of lead poisoning for children. Household dust –dust can become contaminated from deteriorating lead-based paint. Soil – soil can become contaminated from exterior lead-based paint. Drinking water – water can become contaminated if plumbing contains lead or lead solder. Certain occupations and hobbies (see below).Occupations/Industries Ammunition/explosives maker Auto repair/auto body work Battery maker Bridge, tunnel repair Bricklayers Building or repairing ships Cable repair Construction Ceramics worker (pottery, tiles) Firing range worker Leaded glass factory worker Industrial machinery/equipment Jewelry maker or repair Junkyard employee Lead miner Melting metal (smelting) Painter Paint/pigment manufacturing Plumbing Pouring molten metal (foundry work) Radiator repair Remodeling/repainting/renovating houses or buildings built before 1978 Removing paint (sandblasting, scraping, sanding, heat gun or torch) Salvaging metal or batteries Welding, metal workersHobbies/Miscellaneous Old painted toys and furniture Food and liquids stored in lead crystal or lead-glazed pottery or porcelain. Remodeling, repairing, renovating home Painting/stripping cars, boats, bicycles Soldering Melting lead for fishing sinkers or bullets Making stained glass Firing guns at a shooting range

Sources of Lead

Appendix 2

Lead Pre-Screening Questionnaire &Consent Form to Obtain a Blood Lead Sample

Child’s Name _____________________________________ DOB ________________

Health Insurance _____________________________ Policy # _____________________

Question AnswerYes No

1. Does your child live in or regularly visit a house/building built before 1978 with peeling or chipping paint, or with recent or ongoing renovation or remodeling?

2. Has your family/child ever lived outside the United States or recently arrived from aforeign country?

3. Does your child have a brother/sister, housemate/playmate being followed or treatedfor lead poisoning?

4. Does your child frequently put things in his/her mouth such as toys, jewelry, or keys? OR does your child eat non-food items?

5. Does your child eat non-food items (dirt, clay, crayons, etc)?6. Does your child frequently come in contact with an adult whose job or hobby involves exposure to

lead?(Ex. House painting, construction, welding, pottery making, fishing, shooting firearms, stained glass)

7. Does your family use traditional medicines, health remedies, cosmetics, powders, spices, or food from other countries?

8. Does your family cook, store, or serve food in leaded crystal, pewter, or pottery from Asia or LatinAmerica?

I authorize the (insert name) Public Health Department to perform a finger stick blood sample (insert venipuncture if applicable) for the purpose of measuring my child’s lead level and release this information to my child’s physician. I have had an opportunity to ask questions which have been answered to my satisfaction. I understand the benefits and risks of receiving this test. I understand the importance of a follow-up venous blood lead test, should it be indicated, to confirm the results of this screening.

I have had the opportunity to review the Agency’s Notice of Privacy Practices that describes my rights and the Agency’s duties with respect to protected health information. The Agency’s Notice is also displayed in the clinic waiting room. The Agency reserves the right to change the privacy practices in the Notice. I may obtain a revised Notice by calling the Agency at (insert phone number). A revised notice will either be sent in the mail or delivered during a regularly scheduled home visit / clinic visit. I consent to the (insert name) providing treatment, obtaining payment and conducting health care operations. I authorize the (insert name) to submit charges and if necessary, health information for my insurance carrier to consider payment for my services. I understand that I will be responsible for any deductibles or co-pays assessed by my health insurance plan.I understand if I do not have health insurance, fees will be determined on a sliding fee scale.

______ Parent/Guardian Signature Date

Nurse Use Only:

Outcome:

□ Blood Screening Not Required at this time □ Parent refused Testing □ Referred to PCP for Testing

□ Lead Care II Test - Sliding Fee Amount __________ □ Paid □ Bill Insurance □ Send Bill

□ Venous Lab Slip Given - Sliding Fee Amount ________ □ Paid □ Send Bill

□ Venous Lead Test Drawn by LHD - Sliding Fee Amount _______ □ Paid □ Bill Insurance □ Send BillRN Notes: ______________________________________________________________________ ____ _________________________________________________________________________________________________________________________________________________________________________ ________

RN Signature ______________________________________ Date ___________________________

High Risk

Appendix 3CAPILLARY BLOOD SAMPLING PROTOCOL

Venous blood testing is the preferred specimen for blood lead analysis and should be used for lead measurement whenever practical. However, capillary testing is an acceptable method for initial blood lead testing if appropriate methods are followed to minimize the risk of contamination. The following procedure has been adapted from the Centers for Disease Control’s Capillary Blood Sampling Protocol.

A. Materials Needed

• Soap • Alcohol swabs. If a surgical or other disinfectant soap is used, alcohol swabs can be

eliminated. • Sterile cotton balls or gauze pads • Examination gloves • Lancets. The type of lancet used is largely a matter of personal preference as long as sterility

is guaranteed. • Microcollection containers • Adhesive bandages • Trash bags suitable for medical waste and containers for sharps. • Storage or mailing containers if needed. If specimens require shipment, follow the U.S.P.S.

or other appropriate regulations for the transport of body fluids. • Laboratory coat and protective glasses.

Materials used in the collection procedure that could contaminate the specimen (for example, blood containers, alcohol swabs, and barrier sprays) must be lead-free. Before selecting equipment for use in blood collection, consult the laboratory about its requirements. In many cases, the laboratory will recommend or supply suitable collection equipment and may pre-check the equipment for lead contamination. Some laboratories will provide “lead-free” tubes for blood lead screening purposes. Some instrument manufacturers also supply collection materials that are pretested for lead content. Plastic containers are better than glass microhematocrit tubes, because the latter have been known to break.

B. Preparing for Blood Collecting

All personnel who collect specimens should be well trained in and thoroughly familiar with the collection procedure and the use of universal precautions against the transmission of blood-borne pathogens.

Collection personnel should wear examination gloves whenever the potential for contact with blood exists. If the gloves are coated with powder, the powder should be rinsed off with tap water.

C. Preparing the Finger for Puncture

NOTE: Puncturing the fingers of infants younger than 1 year of age is not recommended. Puncturing of the heel or toe may be more suitable for these children.

Steps for Preparing the Child’s Finger

1. Wash the child’s hands thoroughly with soap and water, and then dry them with a clean low-lint or plain, unprinted non-recycled towel. Once washed, the finger must not come in contact with any surface, including the child’s other fingers.

2. Grasp the finger (often the middle finger) that has been selected for puncture between your thumb and index finger with the palm of the child’s hand facing up.

3. If not done during washing, massage the fleshy portion of the finger gently to increase circulation.

4. Clean the ball or pad of the finger to be punctured with the alcohol swab. Dry the fingertip using the sterile gauze or cotton ball.

Puncturing the Finger

After the finger is prepared, the puncture and subsequent steps of forming a drop of blood and filling the collection container should be performed quickly and efficiently, since any delay can make collection more difficult (for example, the blood may clot or the child may resist). Several types of lancets are suitable for puncturing children’s fingers. Lancets range from small manual blades and spring-loaded assemblies to disposable self-contained units. The latter are particularly attractive since the blade is automatically retracted into the holder after use, thus reducing the risk for self injury. Many devices are available with a selection of puncture depths suitable for small children or adults.

Make the puncture swiftly, cleanly, and deep enough to allow for adequate blood flow. The site of the puncture should be slightly lateral to the ball of the finger. This region is generally less calloused, which makes puncturing easier and possibly less painful. The first drop of blood contains tissue fluids that will produce inaccurate results; it should be removed with a sterile gauze or cotton ball.

Blood flows better when the punctured finger is kept lower than the level of the heart. Inadequate blood flow can be improved by gently massaging the proximal portion of the finger in a distal direction, then pressing firmly at the distal joint of the punctured finger (restricting blood flow out of the fingertip) and gently squeezing the sides of the fingertip. Avoid excessive squeezing or milking which will cause tissue fluid to be expressed, compromising specimen integrity.

Appendix 4

COUNTY-SPECIFIC SLIDING FEE SCALE

COUNTIES TO INSERT

MOST RECENT

SLIDING FEE SCALE

Starting at 200% of FPLAppendix 5

COUNTY-SPECIFIC LEAD TEST REPORT (#4430)

COUNTIES TO INSERT

COUNTY-SPECIFIC LEAD TEST REPORT FORM

Appendix 6

Public Health Law – Lead Poisoning Prevention Program

§ 1370. Definitions. When used in this title, the following words and phrases shall have the following meanings, unless the context clearly requires otherwise: 1. "Dwelling" means a building or structure or portion thereof, including the property occupied by and appurtenant to such dwelling, which is occupied in whole or in part as the home, residence or sleeping place of one or more human beings and shall, without limiting the foregoing, include child care facilities for children under six years of age, kindergartens and nursery schools. 2. "Area of high risk” means an area designated as such by the commissioner or his representative and consisting of one or more dwellings in which a condition conducive to lead poisoning of children is present. 3. "A condition conducive to lead poisoning" means: (i) paint or other similar surface-coating material containing lead in a condition accessible for ingestion or inhalation or where peeling or chipping of the paint or other similar surface-coating material occurs or is likely to occur; and (ii) other environmental conditions which may result in significant lead exposure. 4. "Program" means the lead poisoning prevention program in the department established pursuant to section thirteen hundred seventy-a of this title. 5. "Council” means the advisory council on lead poisoning prevention established pursuant to section thirteen hundred seventy-b of this title. 6. "Elevated lead levels” means a blood lead level greater than or equal to ten micrograms of lead per deciliter of whole blood or such blood lead level as may be established by the department pursuant to rule or regulation. 7. "Person" means any natural person.

§ 1370-a. Lead poisoning prevention program. 1. The department shall establish a lead poisoning prevention program. This program shall be responsible for establishing and coordinating activities to prevent lead poisoning and to minimize risk of exposure to lead. The department shall exercise any and all authority which may be deemed necessary and appropriate to effectuate the provisions of this title. 2. The department shall: (a) promulgate and enforce regulations for screening children and pregnant women, including requirements for blood lead testing, for lead poisoning, and for follow up of children and pregnant women who have elevated blood lead levels; (b) enter into interagency agreements to coordinate lead poisoning prevention, exposure reduction, identification and treatment activities and lead reduction activities with other federal, state and local agencies and programs; (c) establish a statewide registry of lead levels of children provided such information is maintained as confidential except for (i) disclosure for medical treatment purposes; (ii) disclosure of non-identifying epidemiological data; and (iii) disclosure of information from such registry to the statewide immunization information system established by section twenty-one hundred sixty-eight of this chapter; and

(d) develop and implement public education and community outreach programs on lead exposure, detection and risk reduction. 3. The department shall identify and designate areas in the state with significant concentrations of children identified with elevated blood lead levels as communities of concern for purposes of implementing a childhood lead poisoning primary prevention program, and may, within amounts appropriated, provide grants to implement approved programs. The commissioner of health of a county or part-county health district, a county health director or a public health director and, in the city of New York, the commissioner of the New York city department of health and mental hygiene, shall develop and implement a childhood lead poisoning primary prevention program to prevent exposure to lead-based paint hazards for the communities of concern in their jurisdiction. The department shall provide funding to the New York city department of health and mental hygiene or county health departments to implement the approved work plan for a childhood lead poisoning primary prevention program. The work plan and budget, which shall be subject to the approval of the department, shall include, but not be limited to: (a) identification and designation of an area or areas of high risk within communities of concern; (b) a housing inspection program that includes prioritization and inspection of areas of high risk for lead hazards, correction of identified lead hazards using effective lead-safe work practices and, appropriate oversight of remediation work; (c) partnerships with other county or municipal agencies or community-based organizations to build community awareness of the childhood lead poisoning primary prevention program and activities, coordinate referrals for services, and support remediation of housing that contains lead hazards; (d) a mechanism to provide education and referral for lead testing for children and pregnant women to families who are encountered in the course of conducting primary prevention inspections and other outreach activities; and (e) a mechanism and outreach efforts to provide housing inspections for lead hazards upon request. The commissioner of health of a county or part-county health district, a county health director or a public health director and, in the city of New York, the commissioner of the New York city department of health and mental hygiene, shall also enter into an agreement or subcontract with a municipal government regarding inspection of the paint conditions in dwellings built prior to nineteen hundred seventy-eight for the area defined as the community of concern and may, when qualified staff exists, designate the local housing maintenance code enforcement agency in which the community of concern is located as an agency authorized to administer the provisions of this title pursuant to subdivision one of section thirteen hundred seventy-five of this title. A portion of grant funding received to support the local primary prevention plan may be used to reduce barriers to lead testing of children and pregnant women within the communities of concern, including the purchase of lead testing devices and supplies when the need for such resources is identified within the community. The commissioner, the commissioner of health of a county or part-county health district, a county health director or a public health director and, in the city of New York, the commissioner of the New York city department of health and mental hygiene, is authorized to enter into agreements, contracts, subcontracts or memoranda of understanding with, and provide technical and other resources to, local health officials, local building code officials, real property owners, and community organizations in such areas to

create and implement policies, education and other forms of community outreach to address lead exposure, detection and risk reduction. Primary prevention plans shall target children less than six years of age living in the highest risk housing in the communities of concern identified. The plans shall also take into consideration the extent the weatherization assistance program and other such programs can be used in conjunction with lead-based paint hazard risk reduction. Funding provided for this program shall be used for the activities described in this section and shall not be used for other activities required by this title.

§ 1370-b. Advisory council on lead poisoning prevention. 1. The New York state advisory council on lead poisoning prevention is hereby established in the department, to consist of the following, or their designees: the commissioner; the commissioner of labor; the commissioner of environmental conservation; the commissioner of housing and community renewal; the commissioner of children and family services; the commissioner of temporary and disability assistance; the secretary of state; and fifteen public members appointed by the governor. The public members shall have a demonstrated expertise or interest in lead poisoning prevention and at least one public member shall be representative of each of the following: local government; community groups; labor unions; real estate; industry; parents; educators; local housing authorities; child health advocates; environmental groups; professional medical organizations and hospitals. The public members of the council shall have fixed terms of three years; except that five of the initial appointments shall be for two years and five shall be for one year. The council shall be chaired by the commissioner or his or her designee. 2. Members of the advisory council shall serve without compensation for their services, except that each of them may be allowed necessary and actual expenses which he or she shall incur in the performance of his or her duties under this article.4. The council shall meet as often as may be deemed necessary to fulfill its responsibilities. The council shall have the following powers and duties: (a) To develop a comprehensive statewide plan to prevent lead poisoning and to minimize the risk of human exposure to lead; (b) To coordinate the activities of its member agencies with respect to environmental lead policy and the statewide plan; (c) To recommend the adoption of policies with regard to the detection and elimination of lead hazards in the environment; (d) To recommend the adoption of policies with regard to the identification and management of children with elevated lead levels; (e) To recommend the adoption of policies with regard to education and outreach strategies related to lead exposure, detection, and risk reduction; (f) To comment on regulations of the department under this title when the council deems appropriate; (g) To make recommendations to ensure the qualifications of persons performing inspection and abatement of lead through a system of licensure and certification or otherwise; (h) To recommend strategies for funding the lead poisoning prevention program, including but not limited to ways to enhance the funding of screening through insurance coverage and other means, and ways to

financially assist property owners in abating environmental lead, such as tax credits, loan funds, and other approaches; and (i) To report on or before December first of each year to the governor and the legislature concerning the previous year's development and implementation of the statewide plan and operation of the program, together with recommendations it deems necessary and the most currently available lead surveillance measures, including the actual number and estimated percentage of children tested for lead in accordance with New York state regulations, including age-specific testing requirements, and the actual number and estimated percentage of children identified with elevated blood lead levels. Such report shall be made available on the department's website.

§ 1370-c. Screening by health care providers. 1. The department is authorized to promulgate regulations establishing the means by which and the intervals at which children and pregnant women shall be screened for elevated lead levels. The department is also authorized to require screening for lead poisoning in other high risk groups.5. Every physician or other authorized practitioner who provides

medical care to children or pregnant women, shall screen children or refer them for screening for elevated lead levels at the intervals and using the methods specified in such regulations. Every licensed, registered or approved health care facility serving children including but not limited to hospitals, clinics and health maintenance organizations, shall ensure, by providing screenings or by referring for screenings, that their patients receive screening for lead at the intervals and using the methods specified in such regulations. 3. The health practitioner who screens any child for lead shall give a certificate of screening to the parent or guardian of the child.6. The department shall establish a separate level of payment, subject

to the approval of the director of the budget, for payments made by governmental agencies for screenings performed pursuant to this section by hospitals, as defined in section twenty-eight hundred one of this chapter.

§ 1370-d. Lead screening of child care or pre-school enrollees. 1. Except as provided pursuant to regulations of the department, each child care provider, public and private nursery school and pre-school licensed, certified or approved by any state or local agency shall, prior to or within three months after initial enrollment of a child under six years of age, obtain from a parent or guardian of the child evidence that said child has been screened for lead. 2. Whenever there exists no evidence of lead screening as provided for in subdivision one of this section or other acceptable evidence of the child's screening for lead, the child care provider, principal, teacher, owner or person in charge of the nursery school or pre-school shall provide the parent or guardian of the child with information on lead poisoning in children and lead poisoning prevention and refer the parent or guardian to a primary care provider or the local health authority. 3. (a) If any parent or guardian to such child is unable to obtain lead testing, such person may present such child to the health officer of the county in which the child resides, who shall then perform or arrange for the required screening.

55372293 EXPLORER NO 1C

(b) The local public health district shall develop and implement a fee schedule for households with incomes in excess of two hundred percent of the federal poverty level for lead screening pursuant to section six hundred six of this chapter, which shall vary depending on patient household income.

§ 1370-e. Reporting lead exposure levels. 1. Every physician or authorized practitioner shall give notice of elevated lead levels as specified by the commissioner pursuant to regulation, to the health officer of the health district wherein the patient resides, except as otherwise provided. 2. The commissioner may, by regulation, provide that cases of elevated lead levels which occur (a) in health districts of less than fifty thousand population not having a full-time health officer, or (b) in state institutions shall be reported directly to the department or its district health officer.7. Whenever an analysis of a clinical specimen for lead is performed

by a laboratory or a physician or authorized practitioner, the director of such laboratory or such physician or authorized practitioner shall, within such period specified by the commissioner report the results and any related information in connection therewith to the local and state health officer to whom a physician or authorized practitioner is required to report such cases pursuant to this section.8. The person in charge of every hospital, clinic, or other similar

public or private institution shall give notice of every child with an elevated blood lead level coming under the care of the institution to the local or state health officer to whom a physician or authorized practitioner is required to report such cases pursuant to this section.9. The notices required by this section shall be in a form and filed

in such time period as shall be prescribed by the commissioner.

§ 1371. Manufacture and sale of lead painted toys and furniture. 1. No person shall manufacture, sell or hold for sale a children’s toy or children’s furniture having paint or other similar surface-coating material thereon containing more than .06 of one per centum of metallic lead based on the total weight of the contained solids or dried paint film. 2. The commissioner of health may waive the provisions of this section in whole or in part upon a finding by the commissioner in a particular instance that there is no significant threat to the public health; with respect to miniatures the commissioner shall do so, on terms and conditions he or she shall establish, upon a final judicial or administrative finding that there is no immediate public health threat in that instance.

§ 1372. Use of leaded paint. No person shall apply paint or other similar surface-coating material containing more than .06 of one per centum of metallic lead based on the total weight of the contained solids or dried paint film to any interior surface, window sill, window frame or porch of a dwelling.

§ 1373. Abatement of lead poisoning conditions. 1. Whenever the commissioner or his representative shall designate an area of high risk,

he may give written notice and demand, served as provided herein, for the discontinuance of a paint condition conducive to lead poisoning in any designated dwelling in such area within a specified period of time. 2. Such notice and demand shall prescribe the method of discontinuance of a condition conducive to lead poisoning which may include the removal of paint containing more than one-half of one per centum of metallic lead based on the total weight of the contained solids or dried film of the paint or other similar surface-coating material from surfaces specified by the commissioner or his representative under such safety conditions as may be indicated and the refinishing of such surfaces with a suitable finish which is not in violation of section one thousand three hundred seventy-two of this title or the covering of such surfaces with such material or the removal of lead contaminated soils or lead pipes supplying drinking water as may be deemed necessary to protect the life and health of occupants of the dwelling.10. In the event of failure to comply with a notice and demand, the

commissioner or his representative may conduct a formal hearing upon due notice in accordance with the provisions of section twelve-a of this chapter and on proof of violation of such notice and demand may order abatement of a paint condition conducive to lead poisoning upon such terms as may be appropriate and may assess a penalty not to exceed two thousand five hundred dollars for such violation.11. A notice required by this section may be served upon an owner or occupant of the dwelling or agent of the owner in the same manner as a summons in a civil action or by registered or certified mail to his last known address or place of residence.12. The removal of a tenant from or the surrender by the tenant of a

dwelling with respect to which the commissioner or his representative, pursuant to subdivision one of this section, has given written notice and demand for the discontinuance of a paint condition conducive to lead poisoning shall not absolve, relieve or discharge any persons chargeable therewith from the obligation and responsibility to discontinue such paint condition conducive to lead poisoning in accordance with the method of discontinuance prescribed therefore in such notice and demand.

§ 1374. Receivership. 1. In the event of failure to comply with an order issued pursuant to this title and containing provision for such application, the officer issuing the order may apply to a court of competent jurisdiction in the county wherein the dwelling is located for an order appointing such officer or his designee receiver of the rents of such dwelling for the purpose of effectuating the provisions of such order. 2. An application for appointment of a receiver hereunder shall be on at least ten days’ notice to the owner of the dwelling, effected in the same manner as in an action to foreclose a mortgage. A receiver appointed hereunder shall not have any right superior to those of any mortgagee or lienor of record who has not had at least ten days’ notice, by personal service or registered or certified mail, of the application for appointment of a receiver.13. A receiver appointed hereunder shall have the power to collect the

accrued and accruing rents of the dwelling and shall apply such collected rents to costs and expenses incurred in connection with (a) removing, replacing, repainting and covering surfaces of the dwelling necessary to effectuate the provisions of the order of abatement, (b) interim operation and management of the dwelling, © administration of

the receivership.14. As soon as practicable after completion of his duties, the receiver

shall render a full accounting to the court and, upon payment over of any surplus moneys to the owner or other persons as the court may approve or direct and upon the order of the court, he shall be relieved of any further responsibility or liability in connection with his receivership. § 1375. Enforcement agencies. 1. The commissioner’s designee having jurisdiction, county and city commissioners of health and local housing code enforcement agencies designated by the commissioner’s designee having jurisdiction or county or city commissioner of health shall have the same authority, powers and duties within their respective jurisdictions as has the commissioner under the provisions of this title.15. The commissioner or his representative and an official or agency

specified in subdivision one of this section may request and shall receive from all public officers, departments and agencies of the state and its political subdivisions such cooperation and assistance as may be necessary or proper in the enforcement of the provisions of this title.16. Nothing contained in this title shall be construed to alter or

abridge any duties and powers now or hereafter existing in the commissioner, county boards of health, city and county commissioners of health, the New York City department of housing preservation and development and the department of health, local boards of health or other public agencies or public officials, or any private party. § 1376-a. Sale of consumer products containing lead or cadmium. 1. In the absence of a federal standard for a specific type of product, the commissioner shall establish the maximum quantity of lead or cadmium (and the manner of testing therefore) which may be released from glazed ceramic tableware, crystal, china and other consumer products. Such maximum quantity shall be based on the best available scientific data and shall insure the safety of the public by reducing its exposure to lead and cadmium to the lowest practicable level. The commissioner may amend such maximum quantity (and the manner of testing therefore) where necessary or appropriate for the safety of the public. Until such maximum quantity of lead or cadmium established by the commissioner is effective, no glazed ceramic tableware shall be offered for sale which releases lead in excess of 7 parts per million, or cadmium in excess of .5 parts per million.17. The commissioner is hereby empowered to order the recall of or

confiscation of glazed ceramic tableware, crystal, china or other consumer products offered for sale which do not meet the standards set forth in or pursuant to this section.18. The commissioner of health may waive the provisions of this section

in whole or in part upon a finding by the commissioner in a particular instance that there is no significant threat to the public health; with respect to miniatures the commissioner shall do so, on terms and conditions he or she shall establish, upon a final judicial or administrative finding that there is no immediate public health threat in that instance.

Appendix 7

COUNTY TO INSERT LETTERS

COUNTY-SPECIFIC LETTERS TO PARENT:1. Regarding Need for Confirmatory Testing

2. Encouraging a repeat venous blood lead test if 5-9.9 mcg/dL

3. Reminding that Repeat Venous Blood Lead Test is Due/Overdue

4. Regarding BLL of 10-14 mcg/dL

COUNTY-SPECIFIC LETTERS TO PHYSICIAN:5. Notifying of Child’s Admission for Lead Case Management

6. Notifying of Child’s Discharge from Case Management

COUNTY-SPECIFIC OUTREACH LETTERS:1. Letter to 1 year old children encouraging testing at 12 months of age

2. Letter to 2 year old children encouraging testing at 24 months of age

55372293 EXPLORER NO 1C

Appendix 7

SAMPLE

PARENT LETTER - Child’s Test is between 5 and 9.9mcg/dL

Name and Address of Parent

Date _________________________

Dear ________________________

Your child, _____________________, was recently screened for Lead Poisoning. The results of this test were _______________mcg/dL. This indicates that your child has a little more lead in their blood then most children. We would like to assist you in preventing this level from becoming any higher.

Enclosed you will find information on some of the most common sources of lead poisoning and ways to decrease your child’s exposure. Your doctor may recommend rescreening your child in three to six months with a venous blood draw from the arm. If you have questions about your child’s blood lead level, you may call his or her doctor or contact the Ontario County Public Health Department. At minimum, the New York State Department of Health recommends that all children be lead tested at one year and two years of age.

Sincerely,

Lead Coordinator

Appendix 7

SAMPLE

Monitoring the Effects of the 5 to 9.9mcg/dL Blood Lead Level Letters

Develop an excel spread sheet entitled “Tracking Tool for BLL 5-9.9mcg/dL”A new worksheet will be created for each calendar year.

Each worksheet will include the following data fields, child’s: Last Name First Name Date of Birth Age Previous tests with results and methods used Date latest specimen between 5 to 9.9mcg/dL obtained Test Result Testing Method (venous or capillary) Date Letter Sent Date letter was undeliverable, if applicable Rescreened date, if applicable Rescreened test result and method (v=venous, c=capillary) Length of time between date letter sent and rescreen date Comments

Upon the daily LeadWeb check, the lead coordinator/designee will identify children with blood lead levels between 5 to 9.9mcg/dL. The individual LeadWeb record of these children will be queried to determine:

1. Is the child currently receiving case management services?2. Has the child received case management services in the past?3. Does the child require a confirmatory test?

If the above three questions are NO, the parents of the child will be sent the 5 to 9.9mcg/dL letter with a cc copy to the child’s provider.

The following child’s information will be entered into the excel spread sheet established for that calendar year: Last Name First Name Date of Birth Age Previous tests with results and method (i.e., 1=3.3FS; 2=<4 V; 3=<3.3 FS) Date latest specimen between 5 to 9.9mcg/dL obtained Test Result and Test Method Date Letter Sent

Lead Coordinator/designee will also write a note in the child’s LeadWeb record indicating the 5 to 9.9 mcg/dL letter was sent.

At minimum monthly the records of the children included in the intervention will be queried to determine if the child was retested. If the child was retested the following information will be entered in the excel spread sheet.

Appendix 7

Rescreened date Rescreened test result and method (v=venous, c=capillary) Length of time between date letter sent and rescreen date Comments, if applicable

Every month up to 6 months after the date of the original letter was sent, LeadWeb will be queried and the excel spread sheet updated.

After 6 months if a repeat test has not been performed in children for whom this was NOT their first BLL, the rescreen date will be recorded as NONE signifying that no further query is needed.

After 6 months if a repeat test has not been performed in children for whom this WAS their first BLL, the child’s primary care provider may be contacted to encourage repeat testing.

When a letter is returned to the LHD as undeliverable the lead coordinator will access the spreadsheet and record the date the letter was returned to the LHD. The coordinator may also reach out to the physician on record to obtain a more up-to-date mailing address.

At minimum annually, the results of this initiative will be compiled.The following information will be recorded:

# of Letters Sent % of Undeliverable Letters # of Children with capillary results re-tested within 6 months of receiving the intervention # of Children with venous results re-tested within 6 months of receiving the intervention % of Children with capillary results re-tested within 6 months of receiving the intervention % of Children with venous results re-tested within 6 months of receiving the intervention % of Children retested with results venous or finger stick below 5 mcg/dL % of Children retested with finger stick results 5 – 9.9 mcg/dL % of Children retested with venous results 5 – 9.9mcg/dL % of Children retested with venous results ≥ 10 mcg/dL

Appendix 8

Regional Lead Resource Centers - Childhood Lead Poisoning Prevention Program

Last Update 3/28/2016

Metropolitan/Hudson Valley RegionThe Children's Hospital at Montefiore

Children's Hospital at Montefiore

3415 Bainbridge Avenue, 4th Floor

Bronx, New York 10467

Medical Director

o Morri Markowitz, MD

Phone: (718) 547-2789 ext. 217

Fax: (718) 547-2881/8251

E-mail: [email protected]

Program Coordinator

o Nancy Redkey

Phone: (718) 547-2789

Email: [email protected]

Geographic Area: Nassau, Suffolk, Queens, Bronx, Richmond, Kings, New York, Dutchess, Orange, Putnam, Rockland,

Sullivan, Ulster & Westchester

Central/Eastern RegionUpstate Medical University

SUNY Upstate

Department of Pediatrics

750 East Adams Street, Room 5600

Syracuse, New York 13210

Medical Director

o Howard L. Weinberger, MD

Phone: (315) 363-7584

Fax: (315) 464-6322



http://www.upstate.edu/gch/services/lead_poisoning/



http://www.cham.org/programs-centers/lead-poisoningtreatment-

Appendix 8

Project Coordinator

o Maureen Butler, BSN

Phone: (315) 464-7584

Fax: (315) 464-6322


Sub Contractor: Albany Medical College

391 Myrtle Ave, Suite 3A

Albany, NY 12208

Medical Director

o Carrin Schottler-Thal, MD

Phone: (518) 262-8602

Fax: (518) 262-5589


Project Coordinator

o Hannah DuJack, RN

Phone: (518) 262-8602


Geographic Area: Albany, Broome, Cayuga, Chenango, Clinton, Columbia, Cortland, Delaware, Essex, Franklin, Fulton,

Greene, Hamilton, Herkimer, Jefferson, Lewis, Madison, Montgomery, Oneida, Onondaga, Oswego, Otsego, Rensselaer, St.

Lawrence, Saratoga, Schenectady, Schoharie, Tioga, Tompkins, Warren & Washington

Western RegionKaleida Health/Women & Children's Hospital of Buffalo

Kaleida Health/Women & Children's

Hospital of Buffalo

219 Bryant St

Buffalo, New York 14222

Medical Director

o Melinda S. Cameron, MD

Phone: (716) 878-7324

Fax: (716) 878-7103



http://www.kaleidahealth.org/lead




Appendix 8

Project Coordinator

o Stephanie Kellner

Phone: (716) 878-7324

Fax: (716) 878-7103


Sub Contractor: University of Rochester

University of Rochester Medical Center

Department of Pediatrics

Division of General Pediatrics

601 Elmwood Avenue, Box 777

Rochester, New York 14642

Medical Director

o Stanley Schaffer, MD, MS

Phone: (585) 275-0267

Fax: (585) 273-1037


Associate Director

o James Campbell, MD, MPH

Phone: (585) 489-0545

Fax: (585) 273-1037


Project Coordinator

o Jennifer D. Becker, MPH

Phone: (585) 276-3105

Fax: (585) 273-1037


Geographic Area: Allegany, Cattaraugus, Chautauqua, Chemung, Erie, Genesee, Livingston, Monroe, Niagara, Ontario,

Orleans, Schuyler, Seneca, Steuben & Wayne

Questions or comments: [email protected]

Revised: March 2016

Per Jennifer Becker, MPH/WR Lead Resource Center, Dr. Campbell no longer works at the Center. ***Remove this for next update

mailto:[email protected]?subject=Lead




http://www.golisano.urmc.edu/lead-poisoning


Appendix 8

Occupational Health Clinic Locations and Phone NumbersLast update: April 1, 2016

Western Region

Center for Occupational Health and Environmental Medicine of Western New York, affiliated with Erie County Medical Center

716-898-5858

Finger Lakes Region

Finger Lakes Occupational Health Services, affiliated with the University of Rochester

585-244-4771

800-925-8615

www.urmc.rochester.edu


Central Region

Central New York Occupational Health Center Tier, affiliated with SUNY Upstate Medical University

315-432-8899

www.ohccupstate.org/

Southern Tier Region

Southern Tier Occupational Health Center Tier, affiliated with SUNY Upstate Medical University

607-584-9990

www.ohccupstate.org/

Adirondack Region

Adirondack Occupational Health Center Tier, affiliated with SUNY Upstate Medical University

315-714-2049

www.ohccupstate.org

Mid-Hudson/Eastern Region

Occupational and Environmental Health Center of Eastern New York, affiliated with GHI

518-690-4420

www.occmedgroup.com

http://www.occmedgroup.com/

http://ohccupstate.org/




http://www.urmc.rochester.edu/finger-lakes-occupational-health.aspx

Appendix 8

Lower Hudson Valley Region

Selikoff Centers for Occupational Health, affiliated with the Icahn School of Medicine at Mount Sinai

888-702-0630 (Yonkers, Monroe)

www.mountsinai.org

New York City Region

Selikoff Centers for Occupational Health, affiliated with the Icahn School of Medicine at Mount Sinai

888-702-0630 (Manhattan, Staten Island)

www.mountsinai.org

Bellevue/NYU Occupational & Environmental Medicine Clinic, affiliated with Health and Hospitals Corporation

212-562-4572

www.med.nyu.edu/pophealth/bellevue-nyu-occupational-environmental-medicine-clinic

Long Island Region

Occupational & Environmental Medicine of Long Island, affiliated with Northwell Health

516-492-3297 (New Hyde Park)

631-439-5300 (Islandia)

www.Northwell.edu/oemli


Specialty Agricultural Clinic

New York Center for Agricultural Medicine and Health, affiliated with Bassett Hospital

607-547-6023

800-343-7527

www.nycamh.com

For More Information

Occupational Health Clinic Brochure - Protecting the Workers of New York State

Information for Businesses (PDF) Information for Workers, Retirees and Residents (PDF)

o Spanish (PDF)

For further information, contact your local occupational health clinic, or the New York State Department of Health at 518-402-7900.

Questions or comments: [email protected]

Revised: April 2016

mailto:[email protected]?subject=OHClinics

https://www.health.ny.gov/publications/6538.pdf



http://www.nycamh.com/


http://www.northwell.edu/oemli

http://www.med.nyu.edu/pophealth/bellevue-nyu-occupational-environmental-medicine-clinic

http://www.mountsinai.org/patient-care/service-areas/occupational-health

http://www.mountsinai.org/patient-care/service-areas/occupational-health

Appendix 9

Lead Investigation/Home Visit Report

Child’s Name DOB M F

Current Address Phone:

Parent Physician

Insurance Yes No LeadWeb ID#:

Additional Information:

1. Lead Screening Result: Date:

2. Hgb/Hct (Copy in file) Result: Date:

3. Vitamin/Supplement Yes No

4. Other children in home or who frequent the home under 6

Child’s Name DOB BLLscreen Done If Yes, Result Date Yes No Yes No Yes No Yes No Yes No

5. Comments/Recommendations:

6. Previous Address: 7. Condition of home: 8. Length of time at previous address: 9. Length of time at current address: 10. Own Rent11. Landlord: Address: Phone: 12. Time spent elsewhere: Hr/wk. Address: Contact Name:

13. Where does child play? Attic Basement Neighbors Porch Yard Closets Indoors OVER

Appendix 9

Possible Sources of Lead Exposure - Check ALL that apply

Painted Woodwork/ Windowsills

Cigarette ashes/ashtrays

Ammunition / Gun Hobbyist

Holes in wall Matches Lead water pipes

Toys Jewelry Ceramics

Furniture Batteries Hobbies

Dirt (yard) Fishing sinkers Occupations

Dust Antiques Other_______________

Solder Other_______________

____________ Total

Does your child have a lot of hand/mouth activity?

What types of things does he/she put in mouth?

Education Provided

Nutrition Signs & Symptoms of Lead Poisoning

Handwashing Re-screening Due date:

Follow-up/Recommendation for Medical Assessment with PC Provider

Sources of possible lead exposure Lead Home Visit Packet

Referrals Provided

Child Find / Early Intervention Date:

WIC Date:

Environmental Health or Date: NYS DOH District Office

Navigator Program Date:

Other Date: (specify)

Copies To: Child’s Primary Care Provider Signature:

Appendix 9

Environmental Health or Date: NYS DOH District Office

Appendix 10

24 HOUR DIETARY RECALL

Record everything the child had to eat or drink in the last 24 hours in the chart below.

CHILD’S NAME DOB

NAME OF CAREGIVER PROVIDING INFORMATION Breakfast Amount Lunch Amount Dinner Amount

Mid Morning Snack Mid Afternoon Snack Bedtime Snack

EvaluationThe number of blocks to the right below indicate the recommended number of servings. Check a block for each serving eaten. Unchecked boxes indicate inadequate intake. Include a summary of recall in progress notes. Evaluation should include quality of diet, choice of snacks, fat intake and whether the diet includes sources of Vitamin C and iron.

FOOD GROUPSSERVING SIZE NUMBER OF SERVINGS

Milk, Cheese, Yogurt ½ -1 C.,* milk or yogurt

Grain1 slice bread or ½ bagel1 C. cold, dry cereal½ C. pasta, rice, cooked cereal

Protein 1 oz. Meat, 1 egg1-2 T. peanut butter¼ - ½ C. dried beans

Fruit ½ - 1 raw. ¼ - ½ C. canned3-4 oz. Juice

Vegetables ¼ - ½ C. cooked or raw

* ½ C. for ages 1 and 2; ¾ C. for ages 3 and up

How often does the child eat fried foods, high fat foods (bacon, sausage, hot dogs, etc.) doughnuts, etc.? daily five times weekly three times weekly once weekly

Is the above recall of a typical day? Yes No If no, how is it different?

Referred to: WIC Food Stamps Other (specify)

Appendix 10

Completed by: Date:

Appendix 11

Appendix 12SAMPLE

Lead Poisoning Prevention ProgramFile Summary Sheet

Patient Name: Date of Birth: LeadWeb ID:

Risk Class: 10-14 mcg/dL 15-19 mcg/dL 20-44 mcg/dL 45-69 mcg/dL > 70 mcg/dL

Parents Name: Guardian Name:Address: Address:

Home Phone: Home Phone:Work Phone: Work Phone:

Name/Age of Siblings with Elevated Lead Levels:

Primary Care Dr. Name: Other Contacts:Address:

Phone:

Environmental Contact Name:Phone:

File ContentsFollow-Up Environmental Follow-Up

Yes N/A Original Lab Results Yes N/A Environmental Referral

Yes N/A Lead Result Summary Yes N/A Environmental Inspection Report

Yes N/A Hgb or Hct Results Yes N/A Copy of Notice and Demand (if Hazards Found)

Yes N/A Parent Letter sending edu. materials Yes N/A Letter to Dr. with Inspection Report, if

indicated Yes N/A Home Visit Report Yes N/A Copy of Completion of Abatement Report

Yes N/A Home Visit Report/Letter to PCP Yes N/A Copy of Letter to Dr. with Abatement Report

Yes N/A Exposure Assessment Yes N/A Copy of Notice of Hearing

Yes N/A Nutritional Assessment

Yes N/AReferral to Child Find <3yr >15 mcg/dL. Referral to School District >3yr >15 mcg/dL

Yes N/A Development Assessment/Results

Yes N/A Treatment/Information from PCPComments:

Date: Reason for discharge:

Signature:

Appendix 13

LeadWeb Documentation

How to make an Environmental Referral:

PROTOCOL FOR LEADWEB ENVIRONMENTAL REFERRAL >15

When doing matching of a child with a venous BLL >15 be sure to do an environmental referral as soon as possible but no longer than 1-2 business days of receiving the lab slip.

1. On the “Child Information” page go to the environmental referral. You will get a form with the basic child information and addresses associated with the child.

2. Hit the button “Create a Referral” that is as the child’s current address per the lab slip you are processing.

3. Follow the instructions on the page. The referral is sent to NYSDOH by email.

LeadWeb Case Management Documentation:

In the near future the LeadWeb Nursing Tutorial Manual will be updated to include the Case Management documentation requirements. In the interim, the following are key documentation elements: Demographic data (name, address, DOB, gender, race, ethnicity (Hispanic?), guardian, siblings who may

be at risk Surveillance status PCP if available Complete follow-up services (under first elevated lab results) Primary and secondary addresses where child spends significant time (home, grandparents, home,

neighbors, day care, etc.) Results of developmental screening and nutritional status including iron status for children confirmed at

> 15 mcg/dL (complete the follow -up services page) Enter notes on home visits and other follow- up activities (letters, phone calls, etc.) on (click on "View

all child notes") Record any environmental referrals and the date those were made ( you don't have to use the date that

you are entering the referral- you can back- date it to the day you spoke with or e-mailed environmental staff)

If medical referral/intervention was needed, be sure to complete that screen. Environmental staff need to complete the inspection screens (findings, notice and demand if any,

outcomes, etc.) It is helpful to complete the remaining screens such as education, home visits, etc.

Appendix 14

Local Health Department Lead Poisoning Prevention Staff by County

County Lead Program Coordinator Public Health Educator

Chemung Rebecca Becraft, RN Dawn Bush

Livingston Gail Yunker, RN Yvonne Oliver

Ontario Teresa Shaffer, PHN Christy Richards, PHN

Schuyler Elizabeth Watson, PHS

Janel Walker, Lead Case Mgr.

Elizabeth Watson

Seneca Rochelle Cisco, PHN Kerry VanAuken

Steuben Karen Travis, RN Lorelei Wagner

Wayne Christine Gedney, RN Lisa O’Dell

Yates Sara Christensen, SPHN

Ann Murphy, Lead Case Mgr.

Kathy Swarthout

Appendix 15

Lead Poisoning Prevention ProgramAnticipatory Guidance and

NYS Order Form for Educational Guidance Material

Appendix 15

Anticipatory Guidance

The following outline gives information that may be included in discussions about lead risk reduction with all families. Affirmative answers to the risk assessment questions may provide the practitioner with additional guidance regarding what information should be stressed as part of the anticipatory guidance portion of the encounter.

Effects of lead poisoning Growth and development –may slow a child’s physical and intellectual growth; at very high levels

may cause mental retardation. Behavior –may cause irritability, attention deficit and/or hyperactivity. Bone marrow –interferes with red blood cell production. Kidney –may cause tubular damage; interferes with vitamin D metabolism. Ear –may cause hearing deficits.

Sources and pathways of lead Lead-based paint –exists in older housing. Sanding, scraping or burning paint during renovation

increases hazards. Deteriorating paint may flake and create dust. Children may chew on painted surfaces or transfer the dust to their mouth after touching these surfaces.

Soil or dust –weathered and deteriorated lead-based paint may contaminate soil or dust around older houses.

Drinking water –corrosive water in contact with lead pipes or lead soldered pipes. Occupation and hobbies –construction or demolition workers or workers in smelters, foundries,

battery factories and other lead-related industries may bring home highly concentrated lead dust on their skin or clothing. Engaging in artwork with stained glass and ceramics, fishing weights or hunting shot may result in lead exposure.

Airborne lead –may result from industries such as smelters, battery burning, or home repair or renovation.

Food – acidic food in contact with lead containing pottery, glass or antique pewter can containing elevated levels of lead. Imported foods may come in lead soldered cans. Water used in cooking, food preparation and formula preparation may add to the lead content of food.

Folk remedies. Children who have emigrated from other countries to the United States. Consumer products containing lead.

Pathways of lead absorption Ingestion – principal route of lead absorption. Small children put things into their mouths, which

transfers lead – laden dust form the environment into their bodies. Inhalation – another important route of lead exposure. Lead-laden dust may be absorbed through the

lungs. Dust may be increased during building renovation. Normal cleaning, vacuuming or sweeping may also increase the availability of lead dust.

Maternal-fetal transfer – lead crosses the placenta.

Appendix 15

Strategies for Reducing Lead Exposure Regularly wash children’s hands especially before meals and snacks and after outdoor play. Wash

children’s toys every day. Houseclean using wet mopping and damp dusting. Recommend thorough cleaning of floors,

windowsills and window wells, kitchen floors and counter tops with a solution containing a heavy-duty household cleaner. Cleaners high in phosphate work particularly well.

If lead dust is suspected, avoid the use of regular vacuum cleaners that may spread the lead dust. Use specially equipped High Efficiency Particulate Air (HEPA) vacuums to clean-up lead dust. Local health departments have additional information of HEPA vacuums.

Run water until cold, at least three minutes before using, which can reduce lead content in water. Workers in occupations or hobbies involving lead should change their clothes before coming home, if

possible. Work clothes should be washed separately from the rest of the laundry. Construction or demolition workers, or workers in smelters, foundries, battery factories and other lead-related industries may bring home highly concentrated lead dust on their skin or clothing. Hobby examples include making stained glass or pottery, fishing weights, making firearms and collecting lead figurines.

Home repairs –recommend keeping children away from remodeling and renovation sites or hobbies.

Appendix 15

New York State Department of HealthFREE Lead Poisoning Prevention Educational Materials

Instructions:

Please fill in the form with your mailing information and circle quantities next to each item. Preview or download publications at http://www.health.ny.gov/environmental/lead/education_materials/index.htm. Call the Lead Program at (518) 402-7600 for orders over the maximum. Orders can be placed via mail or email. No phone orders please, but if you have a question about your order, call the Distribution Center at (518) 465-8170.

Title Pub# Language Quantity

Are you Pregnant? Learn how to Protect Yourself and Your Baby from Lead Poisoning (Brochure)

2593 English 25 50 1002599 Chinese 25 50 1002598 Spanish 25 50 100

At One and Two Testing for Lead is What to Do (11x17 Poster)2549 English 1 5 102550 Spanish 1 5 10

At One and Two Testing for Lead is What to Do (8.5 x 11 Poster) 2547 English 1 5 10

At One and Two, Testing for Lead is What to Do (Stickers)2554 English 25 50 1002581 Spanish 25 50 100

Beware of Lead! Do you know where lead may be hiding? (English, Spanish, Chinese, Italian, Russian, French, Burmese, Karen, Pashto,Creole,Arabic,Nepali,Farsi, and Somali) (Factsheet)

Web-Only Click Here

Get Ahead of Lead (Factsheet) (English, Bosnian, Chinese, Farsi, French, Russian, Urdu, and Vietnamese) (Factsheet)

Web-Only Click Here

Get Ahead of Lead (Factsheet) 2569 Spanish 25 50 100Get Ahead of Lead Good Nutrition Helps Your Family to Get Ahead of Lead (11x17 Poster)

2524 English 1 5 252525 Spanish 1 5 25

Get Ahead of Lead Program Crayons 2587 5 15 25Get Ahead of Lead Leo the Little Lion Learns How to Get Ahead of Lead (Coloring book)

2528 English 25 50 1002542 Spanish 25 50 100

Get Ahead of Lead Leo the Little Lion Learns How to Get Ahead of Lead (Storybook)

2533 English 25 50 1002541 Spanish 25 50 100

http://www.health.ny.gov/environmental/lead/education_materials/fact_sheets/get_ahead/

http://www.health.ny.gov/publications/6517/index.htm

http://www.health.ny.gov/environmental/lead/education_materials/index.htm

Appendix 15

Appendix 15

PUT COUNTY-SPECIFIC LIST OF EDUCATIONAL MATERIALS AND LEAD PROGRAM CHART HERE

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