State and Local Health Dept Surveillance for Childhood National Blood Lead Surveillance System

Form Approved

OMB No. 0920-0337

Specifications for Quarterly Lead Surveillance

Database Submissions

(Childhood Lead Poisoning Prevention Program)

The information requested on this form is collected under the authority of Section 317A of the Public Health Service Act (42 USC 247b-1). Limited identifiable data (e.g., address or location) will be shared with the U.S. Department of Housing and Urban Development and the U.S. Environmental Protection Agency (and others) for the purpose of assessing compliance and enforcing regulations to protect children’s environments.

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. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS E-28, Atlanta, GA 30333, ATTN: PRA (0923-0337).

Required Fields CLPPPs must submit to CDC quarterly

 

Child Data (Required)

Child Last Name *

Child First Name*

Child Middle Initial*

Child ID

DOB (actual)

Age (reported from laboratory or provider)*

Sex

Special Ethnicity

Race (see table below)

Pregnant at time of test (if applicable)*

Child's previous country of residence*

Travel outside of US*

 

Address Data (Required)

Street Address*

Address ID

City

County FIPS

State

Zip Code

Census Tract

Blood Lead Test Data (Required)

Specimen Source for lead test (sample type: venous blood, capillary blood, etc.)

Date sample collected (Sample Date)

Date sample analyzed (Sample Analyze Date)

Laboratory result report date (Result Report Date)

Numeric result comparator (less than, greater than) *

Numeric result value

Numeric result units

Explanation for missing numeric result (e.g., clotting, quantity not sufficient, etc.)*

 

Case Data (Required)

Date case closed*

Closure reason*

Child Risk Assessment Data (Required)

Investigation Data (Required)

Referral date for investigation

Date address investigation inspection completed

Investigation findings of sources

Investigation closure reason*

Date remediation due

Date address hazard remediation or abatement completed

Date clearance testing completed

Clearance testing results

Laboratory Data (Required)

Name of Laboratory that reported test result *

CLIA number *

Limit of Detection for blood lead testing*

 

Provider Data (Required)

Provider/medical group State*

Provider/medical group City*

Provider/medical group County*

Race (Required Format)	Code
American Indian or Alaskan Native	1
Asian	2
Black or African American	3
Native Hawaiian or Other Pacific Islander	5
White	4
Unknown	9
American Indian or Native Alaskan/Asian	A
American Indian or Native Alaskan/Black	B
American Indian or Native Alaskan/Native Hawaiian or Other Pacific Islander	C
American Indian or Native Alaskan/White	D
Asian/Black	E
Asian/Native Hawaiian or Other Pacific Islander	F
Asian/White	G
Black/Native Hawaiian or American Indian	H
Black/White	I
Native Hawaiian or Other Pacific Islander/White	J
American Indian/Asian/Native Hawaiian	K
American Indian/Black/Native Hawaiian	L
American Indian/Asian/Black	M
American Indian/Asian/White	N
American Indian/Black/White	O
American Indian/Native Hawaiian/White	P
Asian/Black/Native Hawaiian	Q
Asian/Black/White	R
Asian/Native Hawaiian/White	S
Black/Native Hawaiian/White	T
American Indian/Asian/Black/White	U
American Indian/Black/Native Hawaiian/White	V
Asian/Black/Native Hawaiian/White	W
Black/American Indian/Asian/Native Hawaiian	X
Native Hawaiian/American Indian/Asian/White	Y
American Indian/Asian/Black/Native Hawaiian/White	Z

Format for submitting data

Table: 1

Record Type: Basic Format

Position	Field Name	Valid Values - Description
1-3	fileid	File identifier for record type. ADD - address data CHI - child INV - investigation LAB - lab LNK - child to address link
4	action	Database action code. A - add record C - change/replace D - delete
5	qtr	Reporting quarter. All annual submissions should be “4" for fourth quarter. 1 - first quarter (1/01/yy - 3/31/yy) 2 - second quarter (4/01/yy - 6/30/yy) 3 - third quarter (7/01/yy - 9/30/yy) 4 - fourth quarter (10/01/yy - 12/31/yy)
6-7	rpt_yr	Reporting year. Last two digits of the reporting year. (Must be numeric.)
8-12	pgmid	Program identifier. A unique identifier for the CLPPP (or lead database) submitting the data. The first two position must contain the state FIPS (Federal Information Processing Standard) code. The next three positions are preassigned for STELLAR databases and must be unique for each lead database within a state (including databases other than STELLAR). You may obtain a program ID from the Lead Poisoning Prevention Branch (LPPB).
13-20	child_id	Child identifier. A unique identifier for a child; must be numeric and zero-filled. This would generally be a system-assigned sequential number within a database. The identifier is used in relational databases to eliminate redundant data. The child information exists only once, in one physical record, and is linked to related records by the child identifier. When records from two or more databases are combined, the combination of pgmid and child_id form a unique identifier within the combined database.
13-20	addr_id	Address identifier. A unique identifier for an address; must be numeric and zero-filled. This would generally be a system-assigned sequential number within a database. The identifier is used in relational databases to eliminate redundant data. The address information exists only once, in one physical record, and is linked to related records by the identifier. When records from two or more databases are combined, the combination of pgmid and addr_id form a unique identifier within the combined database.
21-109	all_the_rest	A variable format area. The contents and format depend on the value in the field fileid.

Table: 2

Record Type: Address

FileId: ADD

Position	Field Name	Valid Values - Description
1-12		Basic format as illustrated in Table 1. REQUIRED
13-20	addr_id	See Table 1. REQUIRED
21-35	city	City name.
36-38	cnty_fips	County FIPS code. REQUIRED Numeric, zero-filled. A file of counties and assigned FIPS codes is available from Lead Poisoning Prevention Branch.
39-47	zip	Zip code (5+4 format, no dash). Left justified, blank-fill or zero-fill.
48-49	state	State abbreviation.
50-56	census	Census tract. Left justified, blank-fill.
57	renovated	Residence renovated? 1 - yes, once 2 - no 3 - yes, more than once 9 - unknown
58-65	start_ren	Date first renovation begun. (CCYYMMDD) Date must be present when renovated field (col 57) is coded 1 or 3. Date must be blank when renovated field is coded 2 or 9.
66-73	comp_ren	Date latest renovation completed. (CCYYMMDD) Cannot be earlier than start_ren date. Leave blank if renovation is ongoing as of the end of the reporting year.

Table: 3

Record Type: Child

FileId: CHI

Position

Field Name

Valid Values - Description

1-12

Basic format as illustrated in Table 1. REQUIRED

13-20

child_id

See Table 1. REQUIRED

21-28

dob

Child's date of birth. (CCYYMMDD) REQUIRED

Birth date cannot be after the end of the reporting year. Child may not be older than 16 years at the start of the reporting year.

29

gender

1 - male

2 - female

9 - unknown

*30

race

* Multi-racial and Other codes will be eliminated after the 2001 data submission in accordance with OMB guidelines.

Race	Code
American Indian or Alaskan Native	1
Asian	2
Black or African American	3
Native Hawaiian or Other Pacific Islander	5
White	4
Unknown	9
* Multi-Racial	7
* OTHER	8
American Indian or Native Alaskan/Asian	A
American Indian or Native Alaskan/Black	B
American Indian or Native Alaskan/Native Hawaiian or Other Pacific Islander	C
American Indian or Native Alaskan/White	D
Asian/Black	E
Asian/Native Hawaiian or Other Pacific Islander	F
Asian/White	G
Black/Native Hawaiian or American Indian	H
Black/White	I
Native Hawaiian or Other Pacific Islander/White	J
American Indian/Asian/Native Hawaiian	K
American Indian/Black/Native Hawaiian	L
American Indian/Asian/Black	M
American Indian/Asian/White	N
American Indian/Black/White	O
American Indian/Native Hawaiian/White	P
Asian/Black/Native Hawaiian	Q
Asian/Black/White	R
Asian/Native Hawaiian/White	S
Black/Native Hawaiian/White	T
American Indian/Asian/Black/White	U
American Indian/Black/Native Hawaiian/White	V
Asian/Black/Native Hawaiian/White	W
Black/American Indian/Asian/Native Hawaiian	X
Native Hawaiian/American Indian/Asian/White	Y
American Indian/Asian/Black/Native Hawaiian/White	Z

31

sp_ethn

Race/Ethnicity (this field may be left blank)

I - Asian Indian J - Japanese

C -Chinese S - Samoan

F - Filipino G - Guamian

H - Hawaiian M - Hmong

K - Korean O - Other

V - Vietnamese Z - Unknown

32

ethnic

1 – Hispanic 2 - Non-hispanic 9 - Unknown

33

chelated

1 - Yes 2 - No 9 - Unknown

34

chel_type

1 - Inpatient 3 - Both

2 - Outpatient 9 - Unknown

Cannot be blank if chelated field =1. Cannot be 1, 2 or 3 if chelated =2 or 9.

35

fund_source

1 - Public, includes Medicaid 8 - Other

2 - Private insurance 9 - Unknown

3 - Parent self-pay

Cannot be blank if chelated field = 1 or 9.

36

nplsz

Non-paint lead source - other. 1 - Yes

2 - No

9 - Unknown

37

nplsm

Non-paint lead source - traditional medicines.

1 - Yes

2 - No

9 - Unknown

38

nplso

Non-paint lead source – occupation of household member.

1 - Yes

2 - No

9 - Unknown

39

nplsh

Non-paint lead source - hobby of household member.

1 - Yes

2 - No

9 - Unknown

40

nplsp

Non-paint lead source - pottery, imported or improperly fired

1 - Yes

2 - No

9 - Unknown

41

nplsc

Non-paint lead source - child occupation.

1 - Yes

2 - No

9 - Unknown

Table: 4

Record Type: Investigation

FileId: INV

Position	Field Name	Valid Values - Description
1-12		Basic format as illustrated in Table 1. REQUIRED
13-20	addr_id	See Table 1. REQUIRED
21-28	date_ref	Date address referred for investigation. (CCYYMMDD) REQUIRED
29-36	insp_comp	Date address investigation inspection completed. (CCYYMMDD) May not be prior to date_ref.
37-44	abat_comp	Date address hazard remediation or abatement completed. (CCYYMMDD) May not be prior to insp_comp.
45-48	year	Year the dwelling was constructed. (YYYY) Blank if unknown. May not be after reporting year.
49	ownership	1 - Private, owner-occupied 4 - Rental, Section 8 2 - Rental, privately owned 9 - Unknown 3 - Rental, publicly owned
50	dwell_type	1 - Attached, single family 5 - School 2 - Day care center 8 - Other 3 - Detached, single family 9 - Unknown 4 - Multi-unit
51	paint_haz	Dwelling with peeling, chipping, or flaking paint. 1-Yes, interior 4 - No Must be 9 if insp_comp is blank. 2-Yes, exterior 9 - Not inspected 3-Yes, both
52-56	xrf	Highest XRF reading in mg/cm2. (000.0) See Note below.
57-64	dust_floor	Highest floor dust sample reading. (000000.0) See Note below.
65	floor_msr	Unit of measure. U - g/ft2 Cannot be blank if dust_floor >0. P - ppm
66-73	dust_sill	Highest window sill dust sample reading. (000000.0) See Note below.
74	sill_msr	Unit of measure. U - g/ft2 Cannot be blank if dust_sill >0. P - ppm
75-82	dust_well	Highest window well dust sample reading. (000000.0) See Note below.
83	well_msr	Unit of measure. U - g/ft2 Cannot be blank if dust_well >0. P - ppm
84-91	paint	Highest paint chip sample reading. (000000.0) See Note below.
92	paint_msr	Unit of measure. U - g/ft2 Cannot be blank if paint >0. P - ppm M - mg/cm2
93-100	soil	Highest soil sample reading in ppm. (000000.0) See Note below.
101-108	water	Highest water sample reading in ppb. (000000.0) See Note below.
109	indhaz	Industrial hazard near dwelling. 1 - Yes 2 - No 9 - Unknown

Note: Environmental sample results should all be shown right-justified, zero-filled on the left, and formatted with one decimal position. If no decimal value, format with decimal and zero (000500.0).

Table: 5

Record Type: Lab Results

FileId: LAB

Position	Field Name	Valid Values - Description
1-12		Basic format as illustrated in Table 1. REQUIRED
13-20	child_id	See Table 1. REQUIRED
21-28	samp_date	Date sample was drawn. (CCYYMMDD) REQUIRED May not be prior to child date of birth.
29-36	addr_id	Unique identifier of child's primary address on the date sample was drawn. (See Table 1.) Zero-fill if unknown.
37-39	result	Sample result measured in g/dL. Whole number, zero-filled. REQUIRED
40	fund_source	Source of funding for the test. 1 - Public, includes Medicaid 2 - Private insurance 3 - Parent self-pay 8 - Other 9 - Unknown
41	samp_type	Sample type. 1 - Venous, blood lead 2 - Capillary, blood lead 9 - Unknown
42	test_rsn	Test reason. 1 - Screening (asymptomatic child withou previous elevated level) 2 - Clinical suspicion of lead poisoning (child symptomatic) 3 - Confirmatory test following elevated value by fingerstick 4 - Follow-up, child with confirmed elevated level 5 - EP, not for lead-screening * 9 - Unknown/other
43	lab_type	Type of laboratory processing sample. 1 - Public health laboratory 2 - Commercial laboratory 9 - Unknown
44	scrn_site	Type of provider ordering test, or screening site. 1 - CLPPP fixed-site specific to lead 2 - Door to door program 3 - Other fixed-site screening program, e.g. WIC 4 - Private health care provider 5 - Referred for confirmation, no screening information 9 - Unknown/other
45	medicaid	1 - Yes 2 - No 9 - Unknown
46-53	samp_anaz_dt	Date sample analyzed by lab. (CCYYMMDD) May not be prior to samp_date.
54-61	rslt_rpt_dt	Date results reported to/received by health department. (CCYYMMDD) May not be prior to samp_date.

Table: 6

Record Type: Child to address link (Optional record type)

FileId: LNK

Position	Field Name	Valid Values - Description
1-12		Basic format as illustrated in Table 1. REQUIRED
13-20	child_id	Unique child identifier. See Table 1. REQUIRED
21-28	addr_id	Unique address identifier. See Table 1. REQUIRED
29	type_addr	1 - Primary address 2 - Relocation address 3 - Alternative 4 - Supplemental 9 - Unknown
30-37	first_occ	Date the child first occupied or began spending time at address. (CCYYMMDD) REQUIRED May not be after the end of the reporting period.
38-45	last_occ	Date the child moved from or ceased spending time at address. (CCYYMMDD) May not be prior to first_occ date.

NOTE: There should be only one "open" link record per child (last_occ is blank) where address type code is 1 or 2.

A relocation address is considered a primary address to which a child has been permanently moved to

remove them from a hazardous environment.