Infant Sleeping Plan

State of California - Health and Human Services Agency

California Department of Social Services
INDIVIDUAL INFANT SLEEPING PLAN
Date of plan*

MonthDayYear
Date
SECTION A: INFANT'S INFORMATION
Infant's Name*
Gender*
Birth Date*

MonthDayYear
Date
Authorized Representative's Name (Primary Contact)*
Phone Number*
Format: (000) 000-0000.
Authorized Representative's Name (Secondary Contact)
Phone Number
Format: (000) 000-0000.
SECTION B: SLEEPING ENVIRONMENT INFORMATION
CribPlay YardOther
What are the Infant's usual sleeping hours?*
What is the infant's average length of the Infant's nap(s) during the day time?*
Minutes and Hours
YesNoSometimes
If yes, brand
SECTION C: INFANT'S ABILITY TO ROLL
My child is able to roll from their back to their stomach and stomach to their beginning

MonthDayYear
as of date
Authorized Representative Signature

Clear
Date

MonthDayYear
Date
SECTION D: INFANT'S ABILITY TO ROLL IN CHILD CARE

Provider observed the infant is capable of rolling from their back to their stomach and stomach to their back.
Provider Signature

Clear
Date

MonthDayYear
Date
Authorized Representative Signature (To be completed no later than the next business day following observation)
Authorized Representative Signature
Date

MonthDayYear
Date
SECTION E: MEDICA EXEMPTION
YesNo
If the infant has a medical exemption to sleep in a position other than on their back a licensed physician must provide instruction on an alternate sleeping position. The following shall be included with the medical exemption:
- Instructions on how the infant shall be placed to sleep, including sleep position.
- Duration the exemption is to be in place
- The licensed physician's contact information
- Signature of the licensed physician and date of signature
ATTACH REQUIRED DOCUMENTS TO THIS FORM AND MAINTAIN IN THE INFANT'S FILE PURSUANT TO TITLE 22, SECTION 101429(a)(2(c) FOR CHILD CARE CENTERS OR SECTION 102425(c)(2) FOR FAMILY CHILD CARE HOMES.
File Upload - Upload your child's medical exemption here

Cancelof
I certify that all information contained in this form is complete and accurate to the best of my ability.
Authorized Representative Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

INDIVIDUAL INFANT SLEEPING PLAN