environmental lead test requistion - michigan · environmental lead test requisition chain of...
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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
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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