Forms

Download the forms you need to facilitate screening at your school or child care facility.

• Bundled forms: The links below include all the forms you need in one PDF document.
  • FORMS IN ENGLISH
  • FORMS IN SPANISH
• Specific forms: Here are links to the Consent Form, Registration Form and HIPPA info.
  • Consent Form in ENGLISH and SPANISH
  • Registration Form in ENGLISH and SPANISH
  • HIPPA info in ENGLISH and SPANISH

Resources from Marion County

• CHILDHOOD LEAD POISONING PREVENTION IN MARION COUNTY
• THE EFFECT OF LEAD ON CHILDREN’S EDUCATION
• JUST THE FACTS FOR PARENTS OR GUARDIANS
• MARION COUNTY LEAD RISK INTERACTIVE MAP
• MISSION UNLEADED APP ON ITUNES AND GOOGLE PLAY

Content for Kids

This kid-friendly language may help your students understand the testing process.

LEAD TESTING: STEP BY STEP

Find Forms

• Forms for Lead Screening at Schools and Child Care Facilities: These are the forms you’ll complete and return to your child’s school or child care facility. Please review the HIPPA policy before completing the registration form. The links below link to a PDF document that includes all the forms you need.
  • FORMS IN ENGLISH
  • FORMS IN SPANISH
• Specific forms: Looking for a particular form? Here are links to the Consent Form, Registration Form and HIPPA info.
  • Consent Form in ENGLISH and SPANISH
  • Registration Form in ENGLISH and SPANISH
  • HIPPA info in ENGLISH and SPANISH

Discover Resources

• BLOOD LEAD LEVELS IN CHILDREN. Read more about children’s blood lead levels and how they are tested in this article from the CDC.
• CAN YOUR CERAMIC COOKWARE GIVE YOU LEAD POISONING? An article from National Public Radio.
• CERAMICWARE IMPORT ALERT. An up-to-date list from the Food and Drug Administration of ceramicware “with excessive lead or cadmium residue” by country and manufacturer.
• HAZARDOUS WASTE DROP-OFF SITES. Where and when to drop off items in the city of Indianapolis, plus a list of items you can drop off.
• HOW TO PREVENT CHILDREN’S EXPOSURE TO LEAD BEFORE THEY ARE HARMED
• LEAD ABATEMENT CONTRACTORS. Search for lead-abatement contractors through the Indiana Professional Licensing Agency or the Environmental Protection Agency.
• LEAD IN FOODS, COSMETICS AND MEDICINES. Detailed information on items known to contain lead from the CDC.
• LEAD IN LIPSTICK. A report from SafeCosmetics.org.
• LEAD IN POTTERY. A Q&A from the CDC on lead-glazed traditional pottery.
• LEAD POISONING. Information from the World Health Organization on sources of lead exposure and the effects on children.
• LEAD POISONING PREVENTION. Information on protecting children from lead poisoning by the CDC.
• LEAD RISK LEVELS AND PREVENTION. Tips from the Lead and Healthy Homes Division of the Indiana Department of Health.
• PRODUCT RECALL DATABASE. The Consumer Product Safety Commission’s recall database, safeproducts.gov, and desktop app.
• SOIL TESTING AND HOME GARDENING. An urban gardening guide from the Center for Urban Health at IUPUI.
• SOURCES OF LEAD EXPOSURE. A quick overview of common household dangers for children from the CDC.
• THINK DIRTY APP. A mobile app that allows you to scan barcodes of products as you shop and receive information about their chemical content — including lead.

Health and Nutrition

• FIGHT LEAD POISONING WITH A HEALTHY DIET. Learn about lead poisoning prevention tips for families from the EPA.
• NUTRITION AND LEAD POISONING. Read the comprehensive list of healthy eating and cleanliness habits that can influence the amount of lead absorbed by a child.

• CERTIFIED ABATEMENT FIRMS. A search tool from the EPA.
• GARDEN SAFE, GARDEN WELL. The Indiana Collaboration for Lead Action and Prevention (ICLAP) Urban Gardening Guide has also been published in Spanish: SEMBRADO SEGURO.
• HAZARDOUS WASTE DROP-OFF SITES. Where and when to drop off items in the city of Indianapolis, plus a list of items you can drop off.
• HOME DANGER ZONE FINDER. An introduction to lead hazards in the home from the EPA.
• INDIANA COLLABORATION FOR LEAD ACTION AND PREVENTION. ICLAP provides free lead screening kits for residents of Marion, St. Joseph, Vermillion and Vigo counties.
• LEAD ABATEMENT CONTRACTORS. Search for lead-abatement contractors through the Indiana Professional Licensing Agency or the Environmental Protection Agency.
• LEAD ABATEMENT, INSPECTION AND RISK ASSESSMENT. A starting point for lead abatement from the EPA.
• LEAD-BASED PAINT PSA. A 60-second video from the EPA about renovation risks.
• LEAD DUST IN IMPORTED MINIBLINDS. A factsheet in English and Spanish from the Nevada Childhood Lead Poisoning Prevention Program.
• LEAD IN POTTERY. A Q&A from the CDC on lead-glazed traditional pottery.
• LEAD PROTECTION PROGRAM. The Indiana Housing and Community Development Authority offers free resources to Indiana renters and homeowners.
• LEAD RISK QUIZ. A short quiz from IUPUI to help you estimate the risk of lead in your home.
• THE LEAD-SAFE CERTIFIED GUIDE TO RENOVATE RIGHT. EPA’s overview of lead-safe renovation planning for property owners and families with children under the age of six.
• PROTECT YOUR FAMILY FROM LEAD IN YOUR HOME. A pamphlet from the EPA for prospective buyers and renters of homes built before 1978.
• Q&A FOR HOMEOWNERS AND RENTERS ABOUT UNDERSTANDING LEAD INSPECTIONS, RISK ASSESSMENTS AND ABATEMENTS. Frequently asked questions answered by the EPA.
• Q&A ABOUT LEAD IN OLDER VINYL MINIBLINDS. Learn about lead danger in vinyl miniblinds and how to remove them safely in this pamphlet from Contra Costa Health Services.
• SOIL TESTING AND HOME GARDENING. An urban gardening guide from the Center for Urban Health at IUPUI.
• THE TRUTH ABOUT LEAD PAINT POISONING. Learn about lead paint dangers and how to hire Lead-Safe Certified contractors in this pamphlet from the EPA.

• ENFORCEMENT OF LEAD SAFE HOUSING REGULATIONS. Rules and regulations from the Office of Lead Hazard Control and Healthy Homes.
• HAZARD STANDARDS AND CLEARANCE LEVELS FOR LEAD IN PAINT, DUST AND SOIL. The most recent lead clearance levels from the EPA.
• LEAD ABATEMENT CONTRACTORS. Search for lead-abatement contractors through the Indiana Professional Licensing Agency or the Environmental Protection Agency.
• LEAD ABATEMENT, INSPECTION AND RISK ASSESSMENT. A starting point for lead abatement from the EPA.
• LEAD PAINT SAFETY. A field guide from the Office of Lead Hazard Control and Healthy Homes on renovation best practices, with resources.
• LEAD RENOVATION, REPAIR AND PAINTING PROGRAM. Information about Lead-safe Certification from the EPA.
• LEAD TEST KITS. An outline and description of EPA-approved test kits and information about positive and negative response criteria.
• THE RENOVATION, REPAIR AND PAINTING RULE. An introduction to the EPA RRP rule and HUD Lead Safe Housing Rule.
• STEPS TO LEAD-SAFE RENOVATION, REPAIR AND PAINTING. Guidelines for professionals and DIY workers from the EPA.

• DECADES AFTER BAN, LEAD PAINT LINGERS. An article from Side Effects Public Media about the continuing effects of lead paint.
• LEAD. EPA’s lead resources home page.
• LEAD. A segment from Last Week Tonight with John Oliver about lead poisoning.
• LEAD & HEALTHY HOMES DIVISION. Information about professional licensing and abatement activities from the Indiana Department of Health.
• OFFICE OF LEAD HAZARD CONTROL AND HEALTHY HOMES. OLHCHH provides local and state funding to reduce lead-based paint hazards and enforces HUD’s lead-based paint regulations to help protect children and their families from health and safety hazards in the home.