Infant Safe Sleep Encounter Form

Note: The name of this form was updated to better reflect when it needs to be completed. It was formerly called the Infant Safe Sleep Intervention Checklist and Documentation Survey and it may be called that on program information that you have.

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* 1. Name of EMS Provider/Fire Fighter completing the encounter.

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* 2. EMS Agency/Fire Department Name:

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* 3. County:

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* 4. Enter the date of the encounter.

Date

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* 5. Check all activities that were completed by the provider:
Note: You may check as many boxes as you completed in the encounter. It is not expected that every encounter will have the same actions carried out as each is unique. Please only check what the provider did.

Asked to see the infant’s sleep space.

Evaluated the infant’s sleep space.

Provided infant safe sleep education to the family.

Helped family make their infant sleep space safe (such as removed items from crib/bassinet/pack and play, etc.).

Provided the family with a sleep sack.

Left the Leave Behind Packet with the family.

Provided and helped set up a pack and play (or will be coming back to set it up).

Contacted the local safe sleep resource (local health department, etc.) and they will contact the family directly to come set up the pack and play.

Other - fill in any other activities completed.

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* 6. Share any additional details about the encounter or barriers experienced, if applicable.

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* 7. If the family was provided a pack and play and/or sleep sack, did the parent/caregiver indicate that receiving the item(s) lowered their stress related to caring for their child?

Yes

Not applicable

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* 8. Did the parent/caregiver indicate that they learned at least one new parenting behavior or obtain one new social support as a result of the encounter?

Yes

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* 9. Did the parent/caregiver indicate they were satisfied with the encounter?

Yes

Infant Safe Sleep Encounter Form

Question Title

* 1. Name of EMS Provider/Fire Fighter completing the encounter.

Question Title

* 2. EMS Agency/Fire Department Name:

Question Title

* 3. County:

Question Title

* 4. Enter the date of the encounter.

Question Title

* 5. Check all activities that were completed by the provider:Note: You may check as many boxes as you completed in the encounter. It is not expected that every encounter will have the same actions carried out as each is unique. Please only check what the provider did.

Question Title

* 6. Share any additional details about the encounter or barriers experienced, if applicable.

Question Title

* 7. If the family was provided a pack and play and/or sleep sack, did the parent/caregiver indicate that receiving the item(s) lowered their stress related to caring for their child?

Question Title

* 8. Did the parent/caregiver indicate that they learned at least one new parenting behavior or obtain one new social support as a result of the encounter?

Question Title

* 9. Did the parent/caregiver indicate they were satisfied with the encounter?

* 5. Check all activities that were completed by the provider:
Note: You may check as many boxes as you completed in the encounter. It is not expected that every encounter will have the same actions carried out as each is unique. Please only check what the provider did.