HTML Preview Baby Sleep Chart page number 1.
Sleep Chart
Month: ____________________
Year: _________________
____________________________________________________________________
(name of childcare facility)
N.C. licensing rules require that babies 12 months of age or younger be placed on their back to sleep, unless a signed waiver states otherwise.
Providers must keep a daily record of how they visually check sleeping babies. Keep this record for at least one month after the reporting month.
Providers must decide how often their facility will check sleeping babies.
Note
: Checking every 15 minutes is reasonable.
Instructions: Complete this form each time staff visually checks sleeping infants. Use the chart for an individual baby or list several babies – if you
check them all together. Write the name of each baby checked in the
Name
column. Staff doing the checking must note the times and put their initial.
Check the Sleep Position and Code Letter: B=Back; Si=Side; T=Tummy (Stomach) to indicate the baby’s sleep position when FIRST placed to
sleep and when checked. Write additional comments describing the infant’s sleep such as “rolled over for the first time, ” in the comment space
provided.
Baby’s Name:
Date:
Sleep Time:
Initial:
Position when
FIRST placed
to sleep:
1
Time Checked
& Initial:
Baby’s Position:
2
Time Checked
& Initial:
Baby’s Position:
3
Time Checked
& Initial:
Baby’s Position:
4
Time Checked
& Initial:
Baby’s Position:
5
Time Checked
& Initial:
Baby’s Position:
Name: Date: _______
□ Back Time:__________ Time:____________ Time:___________ Time:____________ Time:___________
_________________ Time: _______
□ S
ide Initial: _________ Initial: ___________ Initial: __________ Initial: ___________ Initial: __________
Initial: _______ □ Tummy
□ B
□
Si □
T □ B
□ Si □ T □
B
□
Si □
T □
B
□
Si □
T □
B
□
Si □
T
Comments:
Name: Date: _______
□ Back Time:__________ Time:____________ Time:___________ Time:____________ Time:___________
_________________ Time: _______
□ S
ide Initial: _________ Initial: ___________ Initial: __________ Initial: ___________ Initial: __________
Initial: _______ □ Tummy
□ B
□
Si □
T □ B
□ Si □ T □
B
□
Si □
T □
B
□
Si □
T □
B
□
Si □
T
Comments:
Name: Date: _______
□ Back Time:__________ Time:____________ Time:___________ Time:____________ Time:___________
_________________ Time: _______
□ S
ide Initial: _________ Initial: ___________ Initial: __________ Initial: ___________ Initial: __________
Initial: _______ □ Tummy
□ B
□
Si □
T □ B
□ Si □ T □
B
□
Si □
T □
B
□
Si □
T □
B
□
Si □
T
Comments:
Name: Date: _______
□ Back Time:__________ Time:____________ Time:___________ Time:____________ Time:___________
_________________ Time: _______
□ S
ide Initial: _________ Initial: ___________ Initial: __________ Initial: ___________ Initial: __________
Initial: _______ □ Tummy
□ B
□
Si □
T □ B
□ Si □ T □
B
□
Si □
T □
B
□
Si □
T □
B
□
Si □
T
Comments:
Sample by: North Carolina Healthy Start Foundation 6/04 Page _____ of _____