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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. 
1.Name of EMS Provider/Fire Fighter completing the encounter.(Required.)
2.EMS Agency/Fire Department Name:(Required.)
3.County:(Required.)
4.Enter the date of the encounter.(Required.)
Date
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.(Required.)
6.Share any additional details about the encounter or barriers experienced, if applicable.
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?(Required.)
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?(Required.)
9.Did the parent/caregiver indicate they were satisfied with the encounter?(Required.)
Current Progress,
0 of 9 answered
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