Check the answer that applies. ☐ ☐ Are there imported non-glossy vinyl mini blinds in the house? Yes No Is there an industrial area within one mile of the house? Yes No ☐ ☐ If yes, type of industry? ☐ ☐ Has any renovation work been done in the past six months? Yes No ☐ ☐ Have you or anyone in the household had lead-safe work practices training? Yes No ☐ ☐ Has painted wood ever been burned in a wood-stove or fireplace? Yes No ☐ ☐ Have ever been emptied onto soil? Yes No ☐ ☐ Does your child play at a park or playground? Yes No Were gasoline or other solvents ever used to clean parts or disposed of at the ☐ ☐ Yes No property? ☐ ☐ Has soil ever been tested for lead? Yes No ☐ ☐ Has the household water ever been tested for lead? Yes No Comments: Check all that apply: Latino: Cosmetics Foods Tamarind Candy Chile flavored candies ☐ ☐ Chocolate-Covered grasshoppers ☐ Remedies Azarcon Liga Maria Luisa Alarcon Coral ☐ ☐ ☐ ☐ ☐ Greta Albayalde Litargiri ☐ ☐ ☐ ☐ Cosmetics Alkohl Kohl Saoott Surma Henna Middle ☐ ☐ ☐ ☐ ☐ Eastern, Sindoor Kum Kum □ □ Indian, Foods Lozeena ☐ Pakistani, African: Remedies ☐ Bali Goli ☐ Ghasard ☐ Kandu ☐ Ayurvedic ☐ Kushta Deshi Dawa Bint Santrinj Bokhoor Cebagin ☐ ☐ ☐ ☐ Al Murrah Southeast Cosmetics Foods Plum Candy Ginger Asian, □ □ Remedies Po Ying Tan Chinese Chuifong Jin Bu Ba-Baw- Pay- ☐ ☐ ☐ ☐ ☐ Tokuwan Huan San Loo-Ah Hai Ge Fen Ju Hua Litharge Cordyceps ☐ ☐ ☐ ☐ Other:
Check the answer that applies. Are there imported non-glossy vinyl mini blinds in the house? ☐ Yes ☐ No Is there an industrial area within one mile of the house? ☐ Yes ☐ No If yes, type of industry? Has any renovation work been done in the past six months? ☐ Yes ☐ No Have you or anyone in the household had lead-safe work practices training? ☐ Yes ☐ No Has painted wood ever been burned in a wood-stove or fireplace? ☐ Yes ☐ No Have ever been emptied onto soil? ☐ Yes ☐ No Does your child play at a park or playground? ☐ Yes ☐ No Were gasoline or other solvents ever used to clean parts or disposed of at the property? ☐ Yes ☐ No Has soil ever been tested for lead? ☐ Yes ☐ No Has the household water ever been tested for lead? ☐ Yes ☐ No Comments: Check all that apply: Latino: Cosmetics Foods ☐ Tamarind Candy ☐ Chile flavored candies ☐ Chocolate-Covered grasshoppers Remedies ☐ Azarcon ☐ Liga ☐ Maria Luisa ☐ Alarcon ☐ Coral ☐ ☐ Greta ☐ Albayalde ☐ Litargiri Middle Eastern, Indian, Pakistani, African: Cosmetics ☐ Alkohl ☐ Kohl ☐ Saoott ☐ Surma ☐ Henna □ Sindoor □ Kum Kum Foods ☐ Lozeena Remedies ☐ Bali Goli ☐ Ghasard ☐ Kandu ☐ Ayurvedic ☐ Kushta ☐ Deshi Dawa ☐ Bint ☐ Santrinj ☐ Bokhoor Cebagin Al Murrah Southeast Asian, Chinese Cosmetics Foods □ Plum Candy □ Ginger Remedies ☐ Chuifong Tokuwan ☐ Jin Bu Huan ☐ Po Ying Tan ☐ Ba-Baw- San ☐ Pay- Loo-Ah ☐ Hai Ge Fen ☐ Ju Hua ☐ Litharge ☐ Cordyceps Other:
EBL%20Case%20Management%20Guide%20Updated%201_24_2017.docx