× Warning message On 10/28/2021, the CDC lowered the blood lead reference value (BLRV) from 5 μg/dL to 3.5 μg/dL. Follow-up care is now recommended for all elevated cases ≥3.5μg/dL. Please select a lead test reporting method This form is secured with end-to-end encryption. Report one test(Enter records one at a time) Report multiple tests(Upload a file) × Status message For this reporting method, you must use the most recent version of the CDPHE Lead Reporting Spreadsheet (Last updated 4/15/2021). Complete all required fields for each case. Upload spreadsheet Upload Upload requirementsOne file only.256 MB limit.Allowed types: xls, xlsx, csv. Submitter Email: Please enter email to receive a confirmation message Test Information Collection date Result date Specimen type Capillary Venous Result μg/dL Enter a numeric value in μg/dL. If the result is below detection, enter the test detection limit preceded by the "<" sign (e.g. <3.3). If the test detection limit is unknown, enter "Low" or "Not detected." × Warning message If this is the patient's first elevated test, a confirmatory venous sample is needed. For capillary tests 3.5-9 μg/dL, complete testing within 3 months. × Warning message If this is the patient's first elevated test, a confirmatory venous sample is needed. For capillary tests 10-19 μg/dL, complete testing within 1 month. × Warning message If this is the patient's first elevated test, a confirmatory venous sample is needed. For capillary tests 20-44 μg/dL complete testing within 2 weeks. × Warning message If this is the patient's first elevated test, a confirmatory venous sample is needed. For capillary tests ≥70 μg/dL complete testing immediately. × Warning message If this is the patient's first elevated test, a confirmatory venous sample is needed. For capillary tests ≥45 μg/dL complete testing within 48 hours. Patient Information First name Last name Date of birth Sex Female Male X Unknown Race (select all that apply) American Indian/Alaska Native Asian Black/African American Native Hawaiian/Pacific Islander White Other Unknown Ethnicity Hispanic/Latinx Non-Hispanic/Latinx Unknown Phone Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code County - None -AdamsAlamosaArapahoeArchuletaBacaBentBoulderBroomfieldChaffeeCheyenneClear CreekConejosCostillaCrowleyCusterDeltaDenverDoloresDouglasEagleEl PasoElbertFremontGarfieldGilpinGrandGunnisonHinsdaleHuerfanoJacksonJeffersonKiowaKit CarsonLa PlataLakeLarimerLas AnimasLincolnLoganMesaMineralMoffatMontezumaMontroseMorganOteroOurayParkPhillipsPitkinProwersPuebloRio BlancoRio GrandeRouttSaguacheSan JuanSan MiguelSedgwickSummitTellerWashingtonWeldYumaUnknown Provider Information Provider name Enter the name of the individual healthcare provider who ordered the lead test. Clinic/Practice phone Clinic/Practice name Enter the name of the healthcare practice where the test was ordered. Clinic/Practice address Clinic/Practice Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Report Submission Information Complete these fields if you are submitting this report from a laboratory or if the information differs from "Clinic/Practice" entered above. Please enter submitter email to receive a confirmation message Submitting provider Submitter phone Submitter Email × Warning message The status of this lead test is elevated (capillary). Please carefully review the next page after you submit your report. × Warning message The status of this lead test is elevated (venous). Please carefully review the next page after you submit your report. Submit Leave this field blank
