Form 0920-1215 Awardee Lead Profile Assessment (ALPH) Email Survey (MS

Attachment 4b

Awardee Lead Profile Assessment (ALPA) (Email Survey – MS Word)

Form Approved

OMB No. 0920-1215

Expiration Date 02/28/2020

Below is the Centers for Disease Control and Prevention’s (CDC) annual assessment for state and local childhood lead poisoning prevention programs (CLPPPs).

You have been asked to take part in this assessment as a state or local public official operating in your official capacity as decision-maker within a CLPPP.

The purpose of the assessment is to identify 1) jurisdictional legal frameworks governing CDC-funded CLPPPs in the United States, and 2) strategies for implementing childhood lead poisoning prevention activities in the United States.

This information collection will allow the CDC CLPPP to identify specific factors that may support or hinder the efforts of public health agencies engaged in lead poisoning prevention. The information collection will inform guidance, resource development, and technical assistance activities the CDC CLPPP conducts in support of the ultimate goal of lead elimination. Assessment findings will be shared with key stakeholders, placed on CDC’s CLPPP website, and used to respond to inquiries by the public, media, and Congress.

The data will be kept secure throughout the analysis and reporting process.

This assessment should take no more than 47 minutes to complete. You may stop taking the assessment and finish it at a later time. To re-enter the web survey, the tool will provide you with a unique link and passcode for return access. Please refer to the Awardee Lead Profile Assessment (ALPA) training manual for instructions on answering each question. Each text box has a character limit of 200 characters.

Please complete the assessment by [SPECIFIC DATE TO BE PROVIDED – 2 WEEKS AFTER THE SURVEY IS SENT OUT].

Participation is required for satisfactory performance. No individually identifiable information will be requested.

If you have programmatic questions, you can contact CDC CLPPP via your Project Officer.

1. Please choose one option below to continue:

ᴏ I agree to participate in the assessment.

ᴏ I do not agree to participate in the assessment. (END OF ASSESSMENT)

CDC estimates the average public reporting burden for this collection of information as 47 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1215).

Section 1: Program Information

2. Program Title (ex. State Childhood Lead Poisoning Prevention Program)

3. City of Program Headquarters

4. State of Program Headquarters

Section 2: State Program Legal Governance

a. Does your jurisdiction have state legislation mandating blood lead screening and/or testing* for:	b. What strategy is the mandate based on?	c. Please specify the ages covered by your jurisdiction’s legislation.
a. Medicaid-enrolled children? ᴏ Yes ᴏ No (skip to question 6a) ᴏ Unknown (skip to question 6a)	5b. ○ Universal screening and/or testing* ○ Targeted screening and/or testing* ○ Both universal and targeted screening and/or testing* ○ Other; please specify: _____________________________	5c. ᴏ All ages are covered ᴏ A select age range is covered, with the maximum age covered being: _____________________________ ᴏ Unknown
a. non-Medicaid-enrolled children? ᴏ Yes ᴏ No (skip to question 7a) ᴏ Unknown (skip to question 7a)	6b. ○ Universal screening and/or testing* ○ Targeted screening and/or testing* ○ Both universal and targeted screening and/or testing* ○ Other; please specify: _____________________________	6c. ᴏ All ages are covered ᴏ A select age range is covered, with the maximum age covered being: _____________________________ ᴏ Unknown
a. pregnant women? ᴏ Yes ᴏ No (skip to question 8) ᴏ Unknown (skip to question 8)	7b. ○ Screening only* ○ Testing only* ○ Both screening and testing* ○ Other; please specify: _____________________________

8. Does your jurisdiction have state legislation mandating the existence or operation of a childhood lead poisoning prevention program?

ᴏ Yes

ᴏ No; it is allowed but not mandated

ᴏ No; it is not allowed

ᴏ Unknown

9. Does your jurisdiction have a state reporting law for blood lead levels?

ᴏ Yes

ᴏ No (skip to question 10)

ᴏ Unknown (skip to question 10)

9a. Please specify the ages covered by your jurisdiction’s legislation

ᴏ All ages are covered

ᴏ A select age range is covered, with the maximum age covered being: _______________________

ᴏ Unknown

9b. Please specify which blood lead levels are required to be reported. (Select one)

ᴏ All blood lead levels

ᴏ Blood lead levels ≥5 µg/dL

ᴏ Blood lead levels ≥10 µg/dL

ᴏ Blood lead levels ≥15 µg/dL

ᴏ Blood lead levels ≥20 µg/dL

ᴏ Blood lead levels ≥45 µg/dL

ᴏ Blood lead levels ≥70 µg/dL

ᴏ Unknown

10. Does your jurisdiction have a state electronic reporting law?

ᴏ Yes

ᴏ No; electronic reporting is allowed but not mandated

ᴏ No; electronic reporting is not allowed

ᴏ Unknown

11. Does your jurisdiction have a state lead paint abatement and/or remediation law(s)?

ᴏ Yes

ᴏ No (skip to question 12)

ᴏ Unknown (skip to question 12)

11a. What strategy(s) is the law(s) based on? (Select all that apply)

□ Regulations regarding the type of building/facility (e.g. childcare centers, Section 8 housing, rental properties, etc.)

□ Regulations regarding the condition of the building/facility (e.g. pre-1978, 2 square feet of deteriorating paint, etc.)

□ Regulations regarding contractors and/or workers that perform abatement

□ Other; please specify:__ _________________________________________________________________

11b. What triggers the law(s)? (Select all that apply)

□ Presence of children

□ Blood lead level

□ Other; please specify:__________________________________________________________________________

11c. Please specify which age range triggers the law(s). (Select one)

ᴏ Children ≤1 years of age

ᴏ Children ≤2 years of age

ᴏ Children ≤3 years of age

ᴏ Children ≤6 years of age

ᴏ Children ≤16 years of age

ᴏ N/A

○ Other; please specify:___________________________________________________________________

11d. Please specify which blood lead levels trigger the law(s). (Select one)

ᴏ All blood lead levels

ᴏ Blood lead levels ≥5 µg/dL

ᴏ Blood lead levels ≥10 µg/dL

ᴏ Blood lead levels ≥15 µg/dL

ᴏ Blood lead levels ≥20 µg/dL

ᴏ Blood lead levels ≥45 µg/dL

ᴏ Blood lead levels ≥70 µg/dL

ᴏ N/A

Section 3: Local Program Legal Governance

12. Are you a local health department or their bona fide agent?

○ Yes

○ No (skip to section 4, question 21)

13. Do any of your jurisdiction’s local legislations regarding childhood lead poisoning prevention differ from your state legislations?

○ Yes

○ No (skip to section 4, question 21)

Does your jurisdiction have local legislation mandating blood lead screening and/or testing* for:	What strategy is the mandate based on?	Please specify the ages covered by your jurisdiction’s legislation.
a. Medicaid-enrolled children? ᴏ Yes ᴏ No (skip to question 15a) ᴏ Unknown (skip to question 15a)	14b. ○ Universal screening and/or testing* ○ Targeted screening and/or testing* ○ Both universal and targeted screening and/or testing* ○ Other; please specify: _____________________________	14c. ᴏ All ages are covered ᴏ A select age range is covered, with the maximum age covered being: _____________________________ ᴏ Unknown
a. non-Medicaid-enrolled children? ᴏ Yes ᴏ No (skip to question 16a) ᴏ Unknown (skip to question 16a)	15b. ○ Universal screening and/or testing* ○ Targeted screening and/or testing* ○ Both universal and targeted screening and/or testing* ○ Other; please specify: _____________________________	15c. ᴏ All ages are covered ᴏ A select age range is covered, with the maximum age covered being: _____________________________ ᴏ Unknown
a. pregnant women? ᴏ Yes ᴏ No (skip to question 17) ᴏ Unknown (skip to question 17)	16b. ○ Screening only* ○ Testing only* ○ Both screening and testing* ○ Other; please specify: _____________________________

17. Does your jurisdiction have local legislation mandating the existence or operation of a childhood lead poisoning prevention program?

ᴏ Yes

ᴏ No; it is allowed but not mandated

ᴏ No; it is not allowed

ᴏ Unknown

18. Does your jurisdiction have a local reporting law for blood lead levels?

ᴏ Yes

ᴏ No (skip to question 19)

ᴏ Unknown (skip to question 19)

18a. Please specify the ages covered by your jurisdiction’s legislation

ᴏ All ages are covered

ᴏ A select age range is covered, with the maximum age covered being: ___________________________________

ᴏ Unknown

18b. Please specify which blood lead levels are required to be reported. (Select one)

ᴏ All blood lead levels

ᴏ Blood lead levels ≥5 µg/dL

ᴏ Blood lead levels ≥10 µg/dL

ᴏ Blood lead levels ≥15 µg/dL

ᴏ Blood lead levels ≥20 µg/dL

ᴏ Blood lead levels ≥45 µg/dL

ᴏ Blood lead levels ≥70 µg/dL

ᴏ Unknown

19. Does your jurisdiction have a local electronic reporting law?

ᴏ Yes

ᴏ No, electronic reporting is allowed but not mandated

ᴏ No, electronic reporting is not allowed

ᴏ Unknown

20. Does your jurisdiction have a local lead paint abatement and/or remediation law(s)?

ᴏ Yes

ᴏ No (skip to question 21)

ᴏ Unknown (skip to question 21)

20a. What strategy(s) is the law(s) based on? (Select all that apply)

□ Regulations regarding the type of building/facility (e.g. childcare centers, Section 8 housing, rental properties, etc.)

□ Regulations regarding the condition of the building/facility (e.g. pre-1978, 2 square feet of deteriorating paint, etc.)

□ Regulations regarding contractors and/or workers that preform abatement

□ Other; please specify:__________________________________________________________________________

20b. What triggers the law(s)? (Select all that apply)

□ Presence of children

□ Blood lead level

□ Other; please specify:__________________________________________________________________________

20c. Please specify which age range triggers the law(s). (Select one)

ᴏ Children ≤1 years of age

ᴏ Children ≤2 years of age

ᴏ Children ≤3 years of age

ᴏ Children ≤6 years of age

ᴏ Children ≤16 years of age

ᴏ N/A

○ Other; please specify:___________________________________________________________________

20d. Please specify which blood lead levels trigger the law(s). (Select one)

ᴏ All blood lead levels

ᴏ Blood lead levels ≥5 µg/dL

ᴏ Blood lead levels ≥10 µg/dL

ᴏ Blood lead levels ≥15 µg/dL

ᴏ Blood lead levels ≥20 µg/dL

ᴏ Blood lead levels ≥45 µg/dL

ᴏ Blood lead levels ≥70 µg/dL

ᴏ N/A

Section 4: Program Surveillance and Prevention Strategy

For the following populations, does your jurisdiction practice a blood lead screening and/or testing* strategy that is different from your jurisdiction’s mandate?	How does your jurisdiction’s practiced blood lead screening and/or testing* strategy differ from your jurisdiction’s mandate? (Select all that apply)	What barriers does your jurisdiction face when practicing blood lead screening and/or testing* strategies? (Select all that apply)
a. Medicaid-enrolled children less than 6 years (72 months) of age? ○ Yes ○ No (skip to question 22a) ○ Unknown (skip to question 22a)	21b. □ Specific interventions are triggered at a lower blood lead level than what is mandated □ Specific interventions are triggered at a higher blood lead level than what is mandated □ Focus is on targeting younger children □ Other; please specify: _____________________________	21c. □ Resources for childhood lead poisoning prevention program □ Resources for screening and/or testing* □ Working with providers □ Education and/or outreach to providers □ Education and/or outreach to public □ Education and/or outreach to targeted populations □ Accessing Medicaid program data □ Other; please specify: _____________________________
a. non-Medicaid-enrolled children less than 6 years (72 months) of age? ○ Yes ○ No (skip to question 23) ○ Unknown (skip to question 23) ○ There is no mandate for non-Medicaid-enrolled children less than 6 years of age (skip to question 23)	22b. □ Specific interventions are triggered at a lower blood lead level than what is mandated □ Specific interventions are triggered at a higher blood lead level than what is mandated □ Focus is on targeting younger children □ Other; please specify: _____________________________	22c. □ Resources for childhood lead poisoning prevention program □ Resources for screening and/or testing* □ Working with providers □ Education and/or outreach to providers □ Education and/or outreach to public □ Education and/or outreach to targeted populations □ Accessing Medicaid program data □ Other; please specify: _____________________________

Section 5: Primary Prevention Strategy

23. Does your childhood lead poisoning prevention program conduct any of the following primary prevention activities? (Select all that apply)

□ Link families with young children at high risk for lead poisoning to housing inspection and environmental intervention resources before a child’s blood lead level becomes elevated

□ Evaluate lead-safe housing status of the community by conducting systematic environmental investigation activities (such as lead dust wipes, visual inspections, paint chip and soil analysis) based on the high-risk status of the housing (i.e. pre-1950 housing in poor condition), compiling those data in an electronic format, and developing an ongoing evaluation component

□ Have codified specifications for lead-safe housing treatments

□ Lead hazard identification has been incorporated into ongoing housing code or other inspections as a result of

partnerships with housing agencies

□ Assure that policy changes needed to promote childhood lead poisoning prevention and lead-safe environments are recommended and supported with data

□ Collaborate with other agencies and organizations and incorporate lead poisoning educational information into

other health, housing, and community services that reach high-risk families

□ Conduct family and community education that support primary prevention activities

□ Conduct professional health education, risk communication, and/or training activities to increase lead poisoning

prevention awareness

□ When a child is identified with an elevated blood lead level, require that environmental testing of adjacent units is conducted

□ Require that housing units identified previously as sources for lead exposure for child are prioritized for remediation

□ Lead-safe training sessions occur at least quarterly

□ Provide resources to help families reduce lead hazards in their homes

□ Require that all lead abatement contractors are certified and that all renovation and other contractors who work in pre-1978 housing are trained in lead-safe work practices

□ Replace lead service lines

□ None of the above

24. Has your jurisdiction’s childhood lead poisoning prevention program developed a lead elimination plan or goal?

○ Yes

○ No (skip to question 25)

○ Unknown (skip to question 25)

24a. Does your jurisdiction’s lead elimination plan have any measures? (Select all that apply)

□ Quantifiable standard

□ Timeline for goals

□ Other; please specify:__________________________________________________________________________

□ None of the above

24b. Does your jurisdiction’s lead elimination plan include any of the following components? (Select all that apply)

□ Primary prevention plan

□ Testing and/or screening* plan

□ CLPPP workplan

□ Laws/regulations and/or policy plan

□ Other; please specify:__________________________________________________________________________

□ None of the above

25. Does your jurisdiction’s childhood lead poisoning prevention program target high-risk areas and/or populations?

○ Yes; Our jurisdiction targets both high-risk areas and populations

○ Yes; Our jurisdiction targets only high-risk areas

○ Yes; Our jurisdiction targets only high-risk populations

○ No

○ Unknown

26. Does your jurisdiction publish GIS maps of high-risk areas and/or populations for public use?

○ Yes, GIS maps of both high-risk areas and populations are published

○ Yes; GIS maps of only high-risk areas are published

○ Yes; GIS maps of only high-risk populations are published

○ No

○ Unknown

Section 6: Program Services

Section 4: Program Services Answer Key

I: ≥5 µg/dL

II: ≥10 µg/dL

III: ≥15 µg/dL

IV: ≥20 µg/dL

V: ≥45 µg/dL

VI: ≥70 µg/dL

VII: Not applicable

At what confirmed blood lead level do you initiate the following actions according to your jurisdiction’s case definition for elevated blood lead level for children less than 6 years (72 months) of age?

Administrative
Action	Mandated Blood Lead Level	Practiced Blood Lead Level
Phone call	27a. ___________	27b. ___________
Mail letter and/or brochure	27c. ___________	27d. ___________
Refer patient for services	27e. ___________	27f. ___________
Begin coordination of services	27g. ___________	27h. ___________
Assessment and Remediation of Residential Lead Exposure
Action	Mandated Blood Lead Level	Practiced Blood Lead Level
Inspection of the child’s home and other sites	28a. ___________	28b. ___________
Obtain a history of the child’s exposure to potential lead hazards	28c. ___________	28d. ___________
Measure environmental lead levels in the home and other sites	28e. ___________	28f. ___________
Educational interventions to reduce ongoing exposure	28g. ___________	28h. ___________
Abatement interventions to reduce ongoing exposure	28i. ___________	28j. ___________
Medical Assessment and Interventions
Action	Mandated Blood Lead Level	Practiced Blood Lead Level
Caregiver lead education (nutritional and environmental)	29a. ___________	29b. ___________
Follow-up blood lead monitoring and testing	29c. ___________	29d. ___________
Complete history and physical exam	29e. ___________	29f. ___________
Complete neurological exam	29g. ___________	29h. ___________
Labwork (e.g. hemoglobin or hematocrit, iron status)	29i. ___________	29j. ___________
Temporary measures for lead hazard reduction	29k. ___________	29l. ___________
Permanent measures for lead hazard reduction	29m. __________	29n. ___________
Neurodevelopmental monitoring	29o. ___________	29p. ___________
Abdominal x-ray with bowel decontamination	29q. ___________	29r. ___________
Chelation therapy	29s. ___________	29t. ___________
Nutritional Assessment and Interventions
Question	Mandated Blood Lead Level	Practiced Blood Lead Level
Diet evaluation	30a. ___________	30b. ___________
Referral to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)	30c. ___________	30d. ___________
Referral to nutritionist	30e. ___________	30f. ___________
Developmental Assessment
Question	Mandated Blood Lead Level	Practiced Blood Lead Level
Conduct developmental assessment	31a. ___________	31b. ___________
Refer for diagnostic evaluation for neurodevelopmental issues	31c. ___________	31d. ___________
Refer for early intervention/stimulation programs	31e. ___________	31f. ___________

32. Are any of these actions implemented by all or some local health departments rather than at the state health department level?

□ Phone call

□ Mail letter and brochure

□ Refer patient for services

□ Begin coordination of services

□ Caregiver lead education (nutritional and environmental)

□ Inspection of the child’s home and other sites

□ Obtain a history of the child’s exposure to potential lead hazards

□ Measure environmental lead levels in the home and other sites

□ Educational interventions to reduce ongoing exposure

□ Abatement interventions to reduce ongoing exposure

□ Follow-up blood lead monitoring and testing

□ Complete history and physical exam

□ Complete neurological exam

□ Labwork (e.g. hemoglobin or hematocrit, iron status)

□ Temporary measures for lead hazard reduction

□ Permanent measures for lead hazard reduction

□ Neurodevelopmental monitoring

□ Abdominal x-ray with bowel decontamination

□ Chelation therapy

□ Diet evaluation

□ Referral to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

□ Referral to nutritionist

□ Conduct developmental assessment

□ Refer for diagnostic evaluation for neurodevelopment issues

□ Refer for early intervention/stimulation programs

□ None of the above (skip to question 34)

33. Are action(s) implemented by the local health department at a different blood lead level than levels set by the state health department?

○ Yes, the actions are implemented at a lower blood lead level

○ Yes, the actions are implemented at a higher blood lead level

○ No, the actions are implemented at the same blood lead level

34. Does your program receive Medicaid reimbursement for any of the following lead poisoning prevention related services? (Select all that apply)

□ Phone call

□ Mail letter and brochure

□ Refer patient for services

□ Begin coordination of services

□ Caregiver lead education (nutritional and environmental)

□ Inspection of the child’s home and other sites

□ Obtain a history of the child’s exposure to potential lead hazards

□ Measure environmental lead levels in the home and other sites

□ Educational interventions to reduce ongoing exposure

□ Abatement interventions to reduce ongoing exposure

□ Follow-up blood lead monitoring and testing

□ Complete history and physical exam

□ Complete neurological exam

□ Labwork (e.g. hemoglobin or hematocrit, iron status)

□ Temporary measures for lead hazard reduction

□ Permanent measures for lead hazard reduction

□ Neurodevelopmental monitoring

□ Abdominal x-ray with bowel decontamination

□ Chelation therapy

□ Diet evaluation

□ Referral to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)?

□ Referral to nutritionist

□ Conduct developmental assessment

□ Refer for diagnostic evaluation for neurodevelopment issues

□ Refer for early intervention/stimulation programs

□ None of the above