Michigan Administrative Code
Department - Health and Human Services
Population Health and Community Services
Heavy Metal and Pesticide Analysis Reporting
Section R. 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 µg/L µg/gram creatinine µg/L
OR
µg/L
MDCH - Bureau of Epidemiology, Division of Occupational and Environmental Epidemiology 3423 N. M.L. King, Jr. Blvd., Lansing, MI 48909 o Fax Number (517) 335-9775 o Phone number (517) 335-8350
