Lead Care II Capillary Blood Lead Testing Reporting Form

This transmission is HIPAA compliant and secure for online reporting of PHI/Personal Medical information.

Type of Submission*

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Submission Date and Time*

Patient Name*

First NameLast Name

Patient Date of Birth*

Sex*

MaleFemaleOtherUnknown

Race*

Ethnicity*

Street Address*

City*

State*

MT

Zip Code*

Country*

United States

Phone Number

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Provider Name*

First NameLast Name

Provider NPI (if known)

Street Address*

City*

State*

MT

Zip Code*

Country*

United States

Provider Phone*

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Performing Facility Name*

Performing Facility CLIA (if known)

Street Address*

City*

State*

MT

Zip Code*

Country*

United States

Type of Test Performed*

Lead [Mass/volume] in Capillary Blood

Test Performed (LOINC)*

Lead in Capillary Blood 10368-9

Date Test Performed*

Date

Specimen Source*

Capillary

Date Specimen Collected*

Date

Test Result*

Numeric Test Result (µg/dL)*

Accession Number/ Specimen ID

Is re-testing scheduled?

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Required items *

The Montana Administrative Rule for reporting lead in blood (ARM 37.114.203) was updated Sept. 2022 to the CDC revised blood lead reference value of 3.5 µg/dL. The updated ARM requires all venous blood lead tests at any level for all ages and capillary blood lead tests equal or greater than 3.5 µg/dL for a person under 16 years of age be reported.

Required patient and provider information with test results must be submitted within seven calendar days. [ARM 37.113.205 and 37.114.205]

All tests reported on this form are understood to be capillary blood tests from Point of Care testing (i.e., LeadCare II devises).

The detectable range of the LeadCare II system is 3.3 to 65 µg/dL. Test results are reported as numeric values with up to one decimal place unless the result is outside the detectable range. Providers should report results that are less than 3.3 µg/dL as “Low" and results greater than 65 µg/dL as "High."

A capillary blood level >3.5 µg/dL needs to be confirmed with a venous specimen test by a
certified laboratory because they are prone to false positive results due to contamination during specimen
collection.The Centers for Disease Control and Prevention (CDC) Guidance on follow-up testing and timing can be found at https://www.cdc.gov/nceh/lead/advisory/acclpp/actions-blls.htm#anchor_164734946270

Lead Care II Capillary Blood Lead Testing Reporting Form

Patient Address

Provider Address

Performing Facility Address