Elevated Blood Lead Level Nursing Case Management Services Provided to the Following Patient Child’s Name: Date of Birth: Address: Parent/Guardian’s Name: EBL NCM Activities Provided (Check all that apply): Health Education Nursing Assessment Plan of Care ☐ ☐ ☐ Assist with ☐ Home Visit Visual ☐ ☐ LSHP Assessment of Application Home for Lead Referrals Made (Check all that apply): Re: Nutrition Re: Housing Re: Medical services ☐ ☐ ☐ all that apply): all that apply): (Check all that apply): WIC Lead home abatement Medicaid/Medicare enrollment Food Pantry Relocation to lead safe housing Children’s Special Health Care Services enrollment Re: Transportation Re: Household Re: Education ☐ ☐ ☐ assistance (Check all that apply): ☐Bus Tickets (Check all that apply): ☐Taxi Voucher Early On Head Start/Early Head Clothing Start Diapers Furniture Other ☐ Nursing Recommendations/Follow-up Activities/Case Disposition: _ _ _ _ Revised 11/21/2016 2
Elevated Blood Lead Level Nursing Case Management Services Provided to the Following Patient Child’s Name: Date of Birth: Address: Parent/Guardian’s Name: EBL NCM Activities Provided (Check all that apply): ☐ Health Education ☐ Nursing Assessment ☐ Plan of Care ☐ Home Visit ☐ Visual Assessment of Home for Lead ☐ Assist with LSHP Application Referrals Made (Check all that apply): ☐ Re: Nutrition all that apply): ☐ Re: Housing all that apply): ☐ Re: Medical services (Check all that apply): WIC Food Pantry Lead home abatement Relocation to lead safe housing Medicaid/Medicare enrollment Children’s Special Health Care Services enrollment ☐ Re: Household assistance (Check all that apply): ☐ Re: Education (Check all that apply): Early On Head Start/Early Head Start ☐ Re: Transportation ☐Bus Tickets ☐Taxi Voucher Clothing Diapers Furniture ☐ Other Nursing Recommendations/Follow-up Activities/Case Disposition: _ _ _ _ Revised 11/21/2016 2
EBL%20Case%20Management%20Guide%20Updated%201_24_2017.docx