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					             INSTRUCTIONS FOR THE CHILDHOOD LEAD POISONING PREVENTION
                                 QUARTERLY REPORT
                                  (OMB NO: 0920-0282)

Purpose

The Quarterly Report is a management tool for statewide and/or community-based childhood lead poisoning
prevention programs (CLPPPs). Information from CLPPP Quarterly Reports will also be used to keep Congress
and others informed about CLPPP activities.

Scope

The Quarterly Report contains quantitative summaries of blood lead testing (screening) performed on individual
children during the grant year quarter. These screening numbers are further categorized by certain demographic
descriptors that help clarify activities occurring within the program’s jurisdiction.


General Instructions

Statewide programs should submit 1) separate reports for each target site receiving CDC financial assistance and
(2 a composite report that includes program data from all communities, regardless of their funding sources.

Make no changes in the design of the report so that data from all CLPPPs can be combined for analysis and
reporting to Congress. To permit proper interpretation of the report, you must complete all information blocks.
If you are unable to provide a specific piece of information, please use "N/A"; do not leave blank spaces.
Provide a detailed explanation along with your report for all N/As.

         An electronic copy of this Quarterly Report document in MS Excel is available on our website
          (ftp://ftp.cdc.gov/pub/software/solar/qrreportfrm.xls). The STELLAR/SOLAR-QR format report is also
          acceptable. No other substitute forms or formats should be used.

Activities for the quarter should be recorded by the date that they actually occurred, not by the date the
CLPPP received the information. Make every effort to enter information into the CLPPP record system for all
activities conducted during the reporting quarter prior to the preparation of the Quarterly Report.

Please include the name and telephone number of the person responsible for preparing the Quarterly Report.
Mail the original and two copies of each report to:

                                               Mildred Garner
                                         Grants Management Officer
                                    Procurement and Grants Office (E 14)
                                  Centers for Disease Control and Prevention
                                     2920 Brandywine Road, Room 3000
                                        Atlanta, Georgia 30341-4146
OMB-APPROVED FORMS:


Public reporting burden for this collection of information is estimated to average 2 hours per response, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for reducing this burden to PHS Reports
Clearance Officer; ATTN: PRA; Hubert H. Humphrey Blg, Rm 721-H; 200 Independence Ave., SW;
Washington, DC 20201, and to the Office of Management and Budget; Paperwork Reduction Project
(0920-0282); Washington, DC 20503.


Instructions for Specific Report Fields
Program Name: Enter name of your Childhood Lead Poisoning Prevention Program.

Cooperative Agreement #: Enter your unique agreement identifier assigned by CDC.

Period Covered (Grant Year Quarter): Enter the grant year of the quarter covered in this report.

Beginning: Enter the date (month, day, year) of the FIRST day of the quarter covered by this report. (For
reporting purposes, quarters begin on January 1, April 1, July 1, or October 1.)

Ending: Enter the date (month, day, year) of the LAST day of the quarter covered by this report. (For reporting
purposes, quarters end on March 31, June 30, September 30, or December 31.)

Report Prepared by: Enter the name of the person preparing this report.

Signature: Enter the signature of the person preparing this report.



DEFINITIONS


FOR THE PURPOSES OF THIS REPORT, THE FOLLOWING DEFINITIONS SHOULD BE USED


CONFIRMATION:
        A confirmatory PbB measurement is generally defined as one of the following: a venous blood sample
        measurement, or a second capillary PbB measurement if the first capillary PbB measurement was
        considered elevated and the second (follow up) PbB level was measured within 12 weeks. A single
        elevated venous PbB measurement is considered both a positive screening test and a confirmatory test.
        CDC recognizes that protocols for confirmation vary by state and locality; therefore, the program clarify
        their confirmation protocol by answering the question below Table 2.
SCREENING:
        A screening test is a laboratory test used to determine whether a child has been exposed to lead. A child
        may have multiple "screening tests" between 6 and 72 months of age, with each routine test considered
        a separate screening.


        For the purposes of this report, children re-tested because of previous elevated blood lead levels should
        not be considered as "screened", and should not be included in the tables found in the quarterly report,
        unless they have a closed case record, or they were confirmed non-elevated prior to this quarter, or the
        last test was more than 6 months prior.


MEDICAID ENROLLED
        Includes Medicaid eligibles and recipients. Eligibles are individuals who have signed for, but have not
        necessarily used services. Recipients are individuals who actually used the services available.
        For the purposes of this report a child will be counted if ever Medicaid Enrolled.


SCREENING AND CONFIRMATION ACTIVITIES.
This section is for reporting screening and confirmation activities of ALL providers (public and private) within
the CLPPP jurisdiction that report to or are monitored by the CLPPP.

TABLE 1 - Number of Children Screened by Age:
This table is for recording information on children whose screening test was conducted during the quarter
covered by this report. In Column A of Table 1, enter the number of individual children who received a blood
lead test by age range. In Column B, enter the number of Medicaid Enrolled children who were blood lead tested
by age range.

TABLE 2 - Number of Children Screened and Confirmed by Blood Lead Level
In Column A, enter the number of children whose initial screening results fell within the listed blood lead level
ranges. In Column B, enter the number of children whose confirmed results fell within the listed blood lead level
ranges. The program should clarify their confirmation protocol by answering the question below Table 2.

TABLE 3 - Number of Children Screened by Ethnicity:
Collection of this information is in accordance with OMB Statistical Policy Directive No. 15. In Table 3, enter
the number of children blood lead screened by the listed ethnicity categories


TABLE 4 - Number of children Screened by Race:
Collection of this information is in accordance with OMB Statistical Policy Directive No 15. In Table 4, enter
the number of children blood lead screened by the listed race categories. Since OMB allows individuals to select
more than one of the five racial categories, the various permutations of answers have been included in this table.