Infant Safe Sleep Certification Program Attestation Form

The Primary Point of Contact for the EMS Agency/Fire Department must certify that all providers have completed an approved training, that an education plan has been developed, and that providers know the process for obtaining resources (when needed) and documenting encounters with families.

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* 1. EMS Agency or Fire Department Name (use your official and complete name)

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* 2. Name of the person completing the survey (must be the EMS Agency/Fire Department Primary Point of Contact)

First Name

Last Name

Title/Position

Email Address

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* 3. I certify that all providers have completed an approved training and documentation is on file at the EMS Agency/Fire Department.

Yes

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* 4. Enter the date when the training requirement was met (must be after 9/15/2021 to meet the requirement). This is the date upon which all providers completed an approved training.

Date

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* 5. List the training type providers completed (MI-TRAIN course #1080336, DOSE program, peer instruction using the approved MDHHS ISS Training, local safe sleep training).

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* 6. If you have providers that could not be trained (on extended leave, only works one shift a month, etc.), please indicate the reason they weren't trained and the plan to get them trained.

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* 7. I certify that the EMS Agency/Fire Department has developed a Infant Safe Sleep Education Plan. (A plan for the agency/department to sustain Infant Safe Sleep training to new hires as well as continuing education to refresh provider knowledge over time.)

Yes

Plan development is in progress

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* 8. I certify that all providers have received training to be able to (check all that apply):

Inquire about an infant’s sleep space.

Inspect the infant’s sleep space and remove hazards.

Educate the family on infant safe sleep .

Offer the Leave Behind packet and sleep sack.

Offer the family a pack and play (when needed).

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* 9. I certify that I have met with the local safe sleep resource (local health department contact, etc.):

Yes (fill in name of contact below)

Meeting scheduled (fill in date of meeting below)

No (provide explanation below)

Fill in information here

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* 10. What is your agency’s/department’s plan for providing a family in need with a pack and play?

Provider contacts the local safe sleep resource (local health department, etc.) and they will follow up with the family directly to arrange to set up a pack and play.

The agency/department has pack and plays on site and the provider (or the primary safe sleep contact) will set up a pack and play.

Other (please specify)

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* 11. If your agency/department keeps pack and plays on site, what is the source:

Local safe sleep resource (local health department, etc.)

EMSC Cache

Other (please specify)

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* 12. I certify that the Infant Safe Sleep Encounter Form will be filled out after every safe sleep encounter with a family. The protocol for your agency/department is:

Every provider is trained on the importance of this form and is expected to fill it out themselves after every safe sleep encounter with a family.

The provider notifies the agency’s/department’s primary safe sleep contact and they will fill out the form on the provider’s behalf. Fill in the primary safe sleep contact below.

Other. Write out the protocol for your agency/department below.

Fill in information here.