South Plains Community Action Association
Head Start & Early Head Start Division
Consent for Lead Testing using a Finger stick Method
P.O. Box 610, 410 Houston, Levelland, Texas 79336
Phone: (806) 894-2207 (800) 658-9632 Fax: (806) 894-2765
Site Name _________________________ Teacher _____________________
Child’s Name _________________________ Sex: [ ] Male or [ ] Female
Medicaid Number _________________________
……………………………………………………………………………………...
Parents, please fill in ALL the blanks between the doted lines. Thank You!!
I ___________________________________give permission for my child
____________________________ to receive blood work (Lead Test).
Parent Signature_______________________________Date________________
Address ______________________________ Date of birth_________________
Ethnicity- please check one: [ ] Hispanic [ ] Non-Hispanic [ ] Unknown
Race: please check one: [ ] White [ ] Black [ ] Native American /Alaska Native
[ ] Asian/ Pacific Islander [ ] Multi-Racial [ ] Unknown
Primary Physician __________________________ City __________________
………………………………………………………………………………….......
Blood work (Lead Test) was drawn on ____________________ for
________________________________.
Results were ____________ug/dL_____Pass/Fail
Nurse Signature ______________________________Date________________
File in Child’s Brown Folder Flap #4 Under Physical Form