Get Form Pb-110: Parent Questionnaire Risk Assessment For Lead ... - Saisd

Filling out the Form Pb-110 is an important step in assessing the potential risk of lead exposure for children. This guide provides clear and comprehensive instructions to help you complete the form accurately and efficiently online.

Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to obtain the form and access it for editing.
2. Begin by entering the patient's name, date of birth, and Medicaid number in the designated fields at the top of the form.
3. Fill in the provider's name and who administered the questionnaire, along with the date of administration.
4. Review question one regarding your child's environment. Indicate if your child lives in a home or facility that was likely built before 1978 or has ongoing repairs.
5. For question two, choose yes, don’t know, or no regarding your child's tendency to eat or chew on non-food items.
6. Question three asks if your child has been in contact with an individual with an elevated blood lead level. Indicate your response.
7. In question four, review and check all applicable occupations or sources of lead exposure. Ensure to note any additional sources if necessary.
8. After answering all questions, review your responses for accuracy before submitting the form.
9. Finally, save your changes, download the completed form, and choose to print or share it as needed.

Complete your documents online today to help ensure the health and safety of your child.