ALPA Questionnaire - Word format

Awardee Lead Profile Assessment (ALPA)

Form Approved

OMB No.0920-xxxx

Expiration Date xx/xx/201x

Welcome to the Centers for Disease Control and Prevention’s (CDC) annual assessment for state and local healthy homes and lead poisoning prevention programs.

You have been asked to take part in this assessment as a state or local public official operating in your official capacity as decision-maker within a lead and healthy homes program.

The purpose of the assessment is to identify 1) jurisdictional legal frameworks governing CDC-funded childhood lead poisoning prevention programs in the United States, and 2) strategies for implementing childhood lead poisoning prevention activities in the United States.

This information collection will allow the CDC Healthy Homes and Lead Poisoning Prevention Program to identify specific factors that may support or hinder the efforts of state and local public health agencies engaged in lead poisoning prevention. The information collection will inform guidance, resource development and technical assistance activities the CDC Healthy Homes and Lead Poisoning Prevention Program conducts in support of the ultimate elimination goal. Assessment findings will be shared on CDC’s Healthy Homes and Lead Poisoning Prevention Program website and in response to inquiries by the public, press, and Congress.

The data will be kept secure throughout the analysis and reporting process.

This assessment should take no more than 7 minutes to complete. You may stop taking the assessment and finish it at a later time. To re-enter the web survey, the tool will provide you with a unique link and passcode for return access. Please do not take this assessment on a mobile device while you are driving.

Please complete the assessment by [BLANK DATE].

Participation is required for satisfactory performance. No individually identifiable information will be requested.

If you have programmatic questions, you can contact CDC Healthy Homes and Lead Poisoning Prevention Program Chief Adrienne S. Ettinger, ScD at [email protected] or 770-488-7492.

1. Please choose one option below to continue:

ᴏ I agree to participate in the assessment.

ᴏ I do not agree to participate in the assessment. (END OF ASSESSMENT)

CDC estimates the average public reporting burden for this collection of information as 7 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Section 1: Program Information

Write your responses into the respective box that follows each question.

2. Program Title (ex. New State Childhood Lead Poisoning Prevention Program)

3. City of Program Headquarters

4. State of Program Headquarters

Section 2: Program Legal Governance

Select a single response for questions 5 – 11. Next, follow directions included after your answer choice, if applicable.

5. Does your jurisdiction have legislation mandating blood lead screening and/or testing for Medicaid-enrolled children?

ᴏ Yes (Continue to question 5a.)

ᴏ No

ᴏ Other (Continue to question 5b.)

5a. If “yes”, please specify the ages covered by your jurisdiction’s legislation

5b. If “other,” please specify

6. Does your jurisdiction have legislation mandating blood lead screening and/or testing for non-Medicaid-enrolled children?

ᴏ Yes (Continue to question 6a.)

ᴏ No

ᴏ Other (Continue to question 6b.)

6a. If “yes”, please specify the ages covered by your jurisdiction’s legislation

6b. If “other,” please specify

7. Does your jurisdiction have legislation mandating blood lead screening and/or testing for pregnant women?

ᴏ Yes

ᴏ No

ᴏ Other (Continue to question 7a.)

7a. If “other”, please specify

8. Does your jurisdiction have legislation mandating the existence or operation of a childhood lead poisoning prevention program?

ᴏ Yes

ᴏ No

ᴏ Other (Continue to question 8a.)

8a. If “other”, please specify

9. Does your jurisdiction have a reporting law for blood lead levels? (answers are a drop down list)

ᴏ Yes (Continue to questions 9a and 9b.)

ᴏ No

ᴏ Other (Continue to question 9c.)

9a. If “yes”, please specify the ages of patients who must have blood lead levels reported

9b. If “yes”, please specify which blood lead levels are required to be reported

9c. If “other”, please specify

10. Does your jurisdiction have an electronic reporting law for laboratories?

ᴏ Yes

ᴏ No

ᴏ Other (Continue to question 10a.)

10a. If “other”, please specify

11. Does your jurisdiction have a lead paint abatement law?

ᴏ Yes (Continue to question 11a.)

ᴏ No

ᴏ Other (Continue to question 11b.)

11a. If “yes”, please describe the action(s) or blood lead level that triggers lead paint abatement

11b. If “other”, please specify

Section 3: Program Surveillance and Prevention Strategy

Select a single response for questions 12 – 15. Next, follow directions included after your answer choice, if applicable.

12. What is your jurisdiction’s mandated blood lead screening and/or testing strategy for Medicaid-enrolled children less than 6 years (72 months) of age?

○ Targeted (Continue to question 12a.)

○ Universal (Continue to question 12a.)

○ Both Targeted and Universal (Continue to question 12a.)

○ Other (Continue to question 12b.)

12a. Please explain your jurisdiction’s mandated screening strategy for Medicaid-enrolled children

12b. If “other”, please specify

13. What is your jurisdiction’s practiced blood lead screening and/or testing strategy for Medicaid-enrolled children less than 6 years (72 months) of age?

○ Targeted (Continue to question 13a.)

○ Universal (Continue to question 13a.)

○ Both Targeted and Universal (Continue to question 13a.)

○ Other (Continue to question 13b.)

13a. Please explain your jurisdiction’s practiced screening strategy for Medicaid-enrolled children

13b. If “other”, please specify

14. What is your jurisdiction’s mandated blood lead screening and/or testing strategy for children less than 6 years (72 months) of age not enrolled in Medicaid?

○ Targeted (Continue to question 14a.)

○ Universal (Continue to question 14a.)

○ Both Targeted and Universal (Continue to question 14a.)

○ Other (Continue to question 14b.)

14a. Please explain your jurisdiction’s mandated screening strategy for non-Medicaid-enrolled children

14b. If “other”, please specify

15. What is your jurisdiction’s practiced blood lead screening and/or testing strategy for children less than 6 years (72 months) of age not enrolled in Medicaid?

○ Targeted (Continue to question 15a.)

○ Universal (Continue to question 15a.)

○ Both Targeted and Universal (Continue to question 15a.)

○ Other (Continue to question 15b.)

15a. Please explain your jurisdiction’s practiced screening strategy for non-Medicaid-enrolled children

15b. If “other”, please specify

Continue to Section 4, beginning on the next page.

Section 4: Program Services

Share your program’s assessment and intervention services for each of the following categories. Use the following roman numeral answer key to record your responses, where indicated.

Section 4: Program Services Answer Key

I: <5 µg/dL

II: 5 – 9 µg/dL

III: 10 – 14 µg/dL

IV: 15 – 19 µg/dL

V: 20 – 44 µg/dL

VI: 45 – 69 µg/dL

VII: ≥70 µg/dL

VIII: Not applicable

16. Administrative.

At what confirmed blood lead level do you initiate the following actions according to your jurisdiction’s case definition for elevated blood lead level for children less than 6 years (72 months) of age?

16a. Phone Call: (Insert roman numeral associated with your answer choice)

16b. Mail Letter and Brochure: (Insert roman numeral associated with your answer choice)

16c. Refer Patient for Services: (Insert roman numeral associated with your answer choice)

16d. Begin Coordination of Services: (Insert roman numeral associated with your answer choice)

16e. Does your program receive Medicaid reimbursement for one or more of the following healthy homes and lead poisoning prevention related services: phone call, mail letter and brochure, refer patient for services, begin coordination of services?

ᴏ Yes (Continue to question 17.)

ᴏ No (Continue to question 16f.)

16f. Is your program pursuing Medicaid reimbursement for one or more of the following healthy homes and lead poisoning prevention related services: phone call, mail letter and brochure, refer patient for services, begin coordination of services?

ᴏ Yes

ᴏ No

17. Assessment and Remediation of Residential Lead Exposure.

At what confirmed blood lead level do you initiate the following actions according to your jurisdiction’s case definition for elevated blood lead level for children less than 6 years (72 months) of age?

17a. Environmental Investigations: (Insert roman numeral associated with your answer choice)

17b. Inspection of the child’s home and other sites: (Insert roman numeral associated with your answer choice)

17c. Obtain a history of the child’s exposure: (Insert roman numeral associated with your answer choice)

17d. Measure environmental lead levels in the home and other sites: (Insert roman numeral associated with your answer choice)

17e. Interventions to reduce ongoing exposure: (Insert roman numeral associated with your answer choice)

17f. Does your program receive Medicaid reimbursement for one or more of the following healthy homes and lead poisoning prevention related services: environmental investigations, inspection of child’s home and other sites, obtain a history of the child’s exposure, measure environmental lead levels in the home and other sites, intervention to reduce ongoing exposure?

ᴏ Yes (Continue to question 18.)

ᴏ No (Continue to question 17g.)

Section 4: Program Services Answer Key

I: <5 µg/dL

II: 5 – 9 µg/dL

III: 10 – 14 µg/dL

IV: 15 – 19 µg/dL

V: 20 – 44 µg/dL

VI: 45 – 69 µg/dL

VII: ≥70 µg/dL

VIII: Not applicable

17g. Is your program pursuing Medicaid reimbursement for one or more of the following healthy homes and lead poisoning prevention related services: environmental investigations, inspection of child’s home and other sites, obtain a history of the child’s exposure, measure environmental lead levels in the home and other sites, intervention to reduce ongoing exposure?

ᴏ Yes

ᴏ No

18. Medical Assessment and Interventions.

At what confirmed blood lead level do you initiate the following actions according to your jurisdiction’s case definition for elevated blood lead level for children less than 6 years (72 months) of age?

18a. Caregiver lead education (nutritional and environmental): (Insert roman numeral associated with your answer choice)

18b. Follow-up blood lead monitoring and testing: (Insert roman numeral associated with your answer choice)

18c. Complete history and physical exam: (Insert roman numeral associated with your answer choice)

18d. Complete neurological exam: (Insert roman numeral associated with your answer choice)

18e. Labwork (e.g. hemoglobin or hematocrit, iron status): (Insert roman numeral associated with your answer choice)

18f. Lead hazard reduction: (Insert roman numeral associated with your answer choice)

18g. Neurodevelopmental Monitoring: (Insert roman numeral associated with your answer choice)

18h. Abdominal x-ray with bowel decontamination: (Insert roman numeral associated with your answer choice)

18i. Chelation Therapy: (Insert roman numeral associated with your answer choice)

18j. Does your program receive Medicaid reimbursement for one or more of the following healthy homes and lead poisoning prevention related services: caregiver lead education (nutritional and environmental), follow-up blood lead monitoring and testing, complete history and physical exam, complete neurological exam, labwork, lead hazard reduction, neurodevelopmental monitoring, abdominal x-ray with bowel decontamination, chelation therapy?

ᴏ Yes (Continue to question 19.)

ᴏ No (Continue to question 18k.)

18k. Is your program pursuing Medicaid reimbursement for one or more of the following healthy homes and lead poisoning prevention related services: caregiver lead education (nutritional and environmental), follow-up blood lead monitoring and testing, complete history and physical exam, complete neurological exam, labwork, lead hazard reduction, neurodevelopmental monitoring, abdominal x-ray with bowel decontamination, chelation therapy?

ᴏ Yes

ᴏ No

Section 4: Program Services Answer Key

I: <5 µg/dL

II: 5 – 9 µg/dL

III: 10 – 14 µg/dL

IV: 15 – 19 µg/dL

V: 20 – 44 µg/dL

VI: 45 – 69 µg/dL

VII: ≥70 µg/dL

VIII: Not applicable

19. Nutritional Assessment and Interventions.

At what confirmed blood lead level do you initiate the following actions according to your jurisdiction’s case definition for elevated blood lead level for children less than 6 years (72 months) of age?

19a. Diet Evaluation: (Insert roman numeral associated with your answer choice)

19b. Referral to the Special Supplemental Nutrition Program for Women, Infants and Children (WIC): (Insert roman numeral associated with your answer choice)

19c. Referral to nutritionist: (Insert roman numeral associated with your answer choice)

19d. Does your program receive Medicaid reimbursement for one or more of the following healthy homes and lead poisoning prevention related services: diet evaluation, referral to WIC, referral to nutritionist?

ᴏ Yes (Continue to question 20.)

ᴏ No (Continue to question 19e.)

19e. Is your program pursuing Medicaid reimbursement for one or more of the following healthy homes and lead poisoning prevention related services: diet evaluation, referral to WIC, referral to nutritionist?

ᴏ Yes

ᴏ No

20. Developmental Assessment.

At what confirmed blood lead level do you initiate the following actions according to your jurisdiction’s case definition for elevated blood lead level for children less than 6 years (72 months) of age?

20a. Conduct developmental assessment: (Insert roman numeral associated with your answer choice)

20b. Refer for diagnostic evaluation for neurodevelopmental issues: (Insert roman numeral associated with your answer choice)

20c. Refer for early intervention/stimulation programs: (Insert roman numeral associated with your answer choice)

20d. Does your program receive Medicaid reimbursement for one or more of the following healthy homes and lead poisoning prevention related services: conduct developmental assessment, refer for diagnostic evaluation for neurodevelopmental issues, refer for early intervention/stimulation programs?

ᴏ Yes (Continue to question 21.)

ᴏ No (Continue to question 20f.)

20e. Is your program pursuing Medicaid reimbursement for one or more of the following healthy homes and lead poisoning prevention related services: conduct developmental assessment, refer for diagnostic evaluation for neurodevelopmental issues, refer for early intervention/stimulation programs?

ᴏ Yes

ᴏ No

21. Comments

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Author	Winston, Tiffany (CDC/OPHSS/CSELS) (CDC)
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File Created	2021-01-21