DCH-0558 (Rev. 4-19) 1 Previous edition obsolete.

ENVIRONMENTAL LEAD TEST REQUISITION MDHHS USE ONLY

Michigan Department of Health and Human Services Date Received @ MDHHS Initials

Bureau of Laboratories – Trace Metals Unit

PO Box 30035 3350 North Martin Luther King Jr. Blvd. Lansing, MI 48909

Phone: 517-335-8059 Fax: 517-335-9871 Web: www.michigan.gov/mdhhslab

Print in UPPERCASE using dark pen

SUBMITTER INFORMATION

Submitter Clinic Code Submitter/Agency

SITE INFORMATION

Address Apartment #

City State Zip Code

MDHHS USE ONLY - PAYMENT

Medicaid/CHIP/SPA HUD GF Flint Supplemental Other

SAMPLE INFORMATION – INDICATE SAMPLE TYPE

Collection Date (MM-DD-YY)

Dust Wipes Soil Food

EBL Same Day Testing

DCH-0558 (Rev. 4-19) 2 Previous edition obsolete.

Sample ID Sample Description

(If food sample include Lot #)

Dust Wipe Area (inches x inches)

Sample # -

MDHHS Use Only

X

X

X

X

X

X

X

X

X

X

X

X

Additional Copy Code Page of

DCH-0558 (Rev. 4-19) 3 Previous edition obsolete.

ENVIRONMENTAL LEAD TEST REQUISITION

CHAIN OF CUSTODY

Released By Released To Date

Released By Released To Date

Released By Released To Date

Released By Released To Date

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.

By Authority of Act 368, P.A. 1978