Safe Sleep Observation Form
Document key details of a safe sleep environment observation using this form.
Observer Name
*
First Name
Last Name
Observer Email
*
example@example.com
Observation Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Infant Sleep Position
*
Back
Side
Stomach
Unknown
Type of Sleep Surface
*
Please Select
Crib
Bassinet
Pack and Play
Adult Bed
Sofa
Other
Location of Sleep
*
Please Select
Home
Hospital
Daycare
Relative's House
Other
Bedding or Soft Items Present
*
Blanket
Pillow
Stuffed Animal
Bumper Pads
None
Other
Room Temperature (°F)
*
Supervision Status
*
Directly Supervised
Checked Periodically
Not Supervised
Safety Concerns Noted
Follow-up Actions or Notes
Submit Observation
Should be Empty: