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Get Kentucky Childhood Lead Poisoning Prevention Program Elevated Blood Lead Level Investigation Risk

Me RA 48# Employer Street City, State Zip Phone: Fax: Email: Signature: Risk Assessment Report Form Date of Assessment: Patient Name: Patient Birth Date: Address: City, Zip: Guardian(s): Phone: Clinical Information: Date Type Location Result Date of Construction: Name of Owner: Address: City, Zip: Phone: GPS Coordinates: Latitude: Longitude: Ownership: Private Section 8 Date First Occupied: Date Last Occupied: Last Renovation Started: Last Renovatio.

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