Alaska health care providers use this 1-page fillable form to report heavy metal results and toxic exposures to the Section of Epidemiology. It covers arsenic, cadmium, cobalt, lead and mercury, with the specimen, collection date and numerical result for each, and serves as Alaska's lead poisoning case report. The form also captures symptoms, the suspected exposure source and any hospitalization.
The health care provider completes the whole form, including patient details, occupation and pregnancy status, results, the attending provider and the laboratory name if known.
Download the current version from the source each time; forms change without notice.
Confidential Heavy Metal and Toxic Exposure Report Form
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
The Section of Epidemiology requires providers to report blood lead levels at or above the CDC blood lead reference value within 7 days. Laboratories and providers must report all blood lead levels within 28 days. This form is the provider's route for those reports.
The form lists arsenic, cadmium, cobalt, lead and mercury, plus an Other row. For each, mark the specimen (urine, blood, serum or other), the collection date and the numerical result. Notes cover symptoms and the suspected exposure source.