DHS Helmet form, Infants

Helmet Approval for Sleeping Infant
This form is to document a licensed professional's approval for an infant under one year of age to wear a helmet while sleeping in a licensed program. No approval is required for an infant to wear a helmet while they are not sleeping or once they turn one year of age. This completed form must be signed by a physician, advanced practice registered nurse, physician assistant, licensed occupational therapist, or licensed physical therapist and remain on file at the licensed location.

By signing this form, I approve this infant to wear a helmet while sleeping for the reason(s) stated below.
Full Name of Child*
Date of birth*

MonthDayYear
Date
Expected number of months of need to wear helmet*
Reason(s) for wearing helmet:*
Name of physician, advanced practice registered nurse, physician assistant, licensed occupational therapist, or licensed physical therapist*
Signature of physician, advanced practice registered nurse, physician assistant, licensed occupational therapist, or licensed physical therapist*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Helmet Approval for Sleeping Infant