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Oklahoma Childhood Lead Poisoning Prevention Program 2012 Lead Exposure Risk Assessment Questionnaire LERAQ CHILD S NAME DATE OF BIRTH Date Age Current Residential Zip Code 1. Does your child have Medicaid SoonerCare If yes this child must have a blood lead th test at 12 and 24 months of age or if older than 24 months at least one test before 6 birthday. Yes No Don t Know with chipped or peeling paint that was built prior to 1950 with renovation repairs or remodeling that were done in the last 6 months that has vinyl or plastic mini blinds has or did have lead poisoning 8. Is your child given any home or folk remedies or cosmetics such as imported items called Greta Azarcon Rudea Kohl or does your child eat food cooked in or served from pottery made outside the United States Examples would be oil field worker bridge painter demolition or renovation of buildings automobile work with batteries or radiators lead solder metal plating furniture refinishing leaded glass lead shot or bullets and lead fishing sinkers. Lead Poisoning Prevention Program Screening and Special Services Oklahoma State Department of Health 1000 NE 10th Street Telephone 405 271-6617 Toll Free 1-800-766-2223 HIGH RISK ZIP CODES 73106 73107 73108 73109 73111 73117 73119 73129 73521 73701 74104 74106 74110 74115 74127 74354 74401 74403 74447 74631 74848 Purpose The LERAQ is to be used to screen for possible lead exposure in children 6 - 72 months of age. Use This assessment may be administered by medical staff or teacher or completed by the child s parent or guardian* Any Yes or don t know answer is considered a positive answer thus requires the child to have a blood lead test. According to OCLPPP Case Management Guidelines if a child has a blood lead test 5 g/dL reassess with the LERAQ in 1 year. No additional testing is necessary unless an exposure risk change has occurred* This Guideline does not supersede the federal CMS requirement that children enrolled in SoonerCare receive a blood lead test at 12 and 24 months of age as defined in the Child Health Check Up also known as Early and Periodic Screening Diagnosis and Treatment EPSDT. Routing and Filing Retain this record in the child s record to review annually. OSDH Form 386-Rev 06/2012. Does your child have Medicaid SoonerCare If yes this child must have a blood lead th test at 12 and 24 months of age or if older than 24 months at least one test before 6 birthday. Yes No Don t Know with chipped or peeling paint that was built prior to 1950 with renovation repairs or remodeling that were done in the last 6 months that has vinyl or plastic mini blinds has or did have lead poisoning 8. Yes No Don t Know with chipped or peeling paint that was built prior to 1950 with renovation repairs or remodeling that were done in the last 6 months that has vinyl or plastic mini blinds has or did have lead poisoning 8. Is your child given any home or folk remedies or cosmetics such as imported items called Greta Azarcon Rudea Kohl or does your child eat food cooked in or served from pottery made outside the United States Examples would be oil field worker bridge painter demolition or renovation of buildings automobile work with batteries or radiators lead solder metal plating furniture refinishing leaded glass lead shot or bullets and lead fishing sinkers.