Section 325.67. Heavy metal analysis report form.

Rule 7. The heavy metal analysis report form reads as follows:

MICHIGAN DEPARTMENT OF COMMUNITY HEALTH HEAVY METAL ANALYSIS REPORT

DATA/INFORMATION REQUIRED BY ADMINISTRATIVE RULE R 325.62

I.  CLIENT INFORMATION

Last name                                                      First name                                                            M.I.

Sex     (M/F)                     Race     (White/Black/Asian/Pacific       Islander/American Indian/Alaskan/mixed)

Ethnicity (Hispanic Y/N)               Birth date or age    Phone number

Street address                                City                                        State/Zip Code/County Name of parent or guardian if individual is a minor

Employer name (if adult)

Employer street address                  City                       State/Zip Code

II. PHYSICIAN/PROVIDER INFORMATION (       )

Provider last name                                         First name              Phone number Provider street address                   City                       State/Zip Code

III. LABORATORY INFORMATION

(        )

Name of testing laboratory                                                          Phone number

Laboratory street address                               City                       State/Zip Code

Date sample taken                                         Date sample analyzed Results

Sample                            Arsenic                  Cadmium Mercury

Blood		µg/ml	µg/L	ng/ml
Urine OR µg/L	µg/L		µg/gram creatinineµg/L

MDCH - Bureau of Epidemiology, Division of Occupational and Environmental Epidemiology 3423 N. M.L. King, Jr. Blvd., Lansing, MI 48909 o Fax Number [phone] o Phone number [phone]

History: 2005 AACS.