LEAD Home Visit Folder Contents

LEAD Home Visit Folder Contents

1) Forms

· Childhood Lead Poisoning Prevention Program “File Summary Sheet” (1) (Left side – stapled)

· Steuben County Public Health BOOKMARK (1)

· Steuben County Public Health Agency Bill of Rights and Services (1)

· Lead Referral/Insurance Authorization

· Order – “Home visit for investigation of an elevated lead level”

i) Evaluated for case management letter to PCP

· Lead Poisoning Prevention Patient Plan of Care/Orders

i) Admitted to case management letter to PCP

· Notice of Privacy (HIPAA) (1)

· Admission/Input Form (index) (1)

· Steuben County Public Health Billing Rates (1)

· Communication for Care and Services Form (1)

· Lead Investigation “Home Visit Report” (1)

· 24 Hour Dietary Recall (1)

· Progress Notes (2-sided) (1)

· Ages & Stages Questionnaire (1) (Not included, nurse will get appropriate form for age of child on home visit)

· Early Intervention/Child Find Referral Form (1)

· WIC Referral Form (1)

· Combined Steuben County Public Health (EI/Child Find, WIC, CPS, blank) (1)

· Community Health Advocates Insurance Referral forms (1) (Not included, nurse will get Family Resources pertinent to family situation (Healthy Families, TASA, SHAPE, etc.)

2) Educational Fact Sheets (1 each)

Note: Initial mailing (x1) to all lead levels 5 and greater. (Terry sends)

· Lead Magnet

· Nutrition and Children/Lead Poisoning Prevention and Nutrition (2-sided) (1)

· Lead and a Healthy Diet/ A Healthy Diet Can Help (2-sided) (1)

[Source: EPA (U.S. Environmental Protection Agency)]

· What Your Child’s Blood Lead Test Means (1)

LEAD Home Visit Educational Packet Contents

1) Product Samples:

· Lead outlet covers (6) “Test at One and Two” (if available)
(NOT contained in packet, need to grab before home visit)

· Sippy cups (1) “Test at One and Two” (if available)

· Radon Kit (1) (if available)

2) Educational Pamphlets: (1 each)

· Poison Proof Your Home
(Source: NYSDOH/rev. 6/09 - #3111) / · SCPH Business Card
(Source: O:drive)
· LEAD on the job A Guide for Workers
(Source: NYSDOH/rev. 04/15 - #2543) / · Sticker: Get Ahead of Lead (w/skater)
(Source: NYSDOH)
· What Home Owners Need to Know…Get Ahead of Lead!
(Source: NYSDOH/rev. 4/08 - #2502) / · Sticker: Get Ahead of Lead “Suds Up”
(Source: NYSDOH)
· …RENOVATE RIGHT!
(Source: EPA/rev. 9/11 – EPA-740-K-10-001) / · Steuben County Children’s Services Directory
· Protect Your Family From Lead In Your Home
(Source: EPA/June 2003 – #EPA747-K-99-001) / · Lead Poisoning is a Danger…
(Source: NYSDOH/rev. 6/12 - #2594)
· Lead Paint Can Poison: Learn the Facts
(Source: HUD) / · Lead Poisoning is a Danger for every baby…
(Source: NYSDOH/rev. 6/12 - #2594)
· Lead Safe Cleaning (Three Bucket Method)
(Source: O:drive) / · Are you Pregnant?
(Source: NYSDOH/rev. 7/15 - #2593)
· Lead Paint Can Poison: Is Your Family at Risk?
(Source: HUD) / · Leo The Little Lion Learns…storybook
(Source: NYSDOH//rev. 5/15 - #2533)
· Poster: At One And Two, Testing for Lead is What to Do.
(Source: NYSDOH/rev. 7/00 - #2547) / · Fight Lead Poisoning with a Health Diet
(Source: EPA/rev. 11/01 - #EPA-747-F-01-004)
· Poster: Wash Lead Out!
(Source: NYSDOH/rev. 6/01 - #2548 / · Eat Healthy to Prevent Lead Poisoning-Steuben
(Source: O:Drive May 2016)
· Coloring Book: Leo The Little Lion Learns…
(Source: NYSDOH/rev. 6/07 - #2528) / · Lead and a Healthy Diet
(Source: EPA)
· Protect Your Family from Radon
(Source: NYSDOH/rev. 12/11 - #3168) / · SCPH Nutrition and Children
(Source: O:drive)
· A Citizen’s Guide to Radon
(Source: NYSDOH/rev. 11/11 - #3153) / · Cultural Products Flyer-Steuben
(Source: O:drive rev 9/11/17)
· Radon Detector Order Form
(Source: NYSDOH/rev. 1/15 - #2247) / · What Your Child’s Blood Lead Test Means
(Source: NYSDOH/rev. 7/15 - #2526)
· Radon Test Kit Instructions
(Source: O:Drive/rev. 1/17) / · Nutrition Poster
(Source: NYSDOH/rev. 2/04 - #2524)

O:\Policies\Lead Policies (SAY)\Contents LEAD Home Visit Folder_Home Visit Educational Packet Contents.doc Rev. 10/05/2017