Baby Sleep Chart Template
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3Sleep Chart
Month: ____________________
Year: _________________
____________________________________________________________________
(name of childcare facility)
N.C. licensing rules require that babies 12 months of age or younger be placed on their back to sleep, unless a signed waiver states otherwise.
Providers must keep a daily record of how they visually check sleeping babies. Keep this record for at least one month after the reporting month.
Providers must decide how often their facility will check sleeping babies. Note: Checking every 15 minutes is reasonable.
Instructions: Complete this form each time staff visually checks sleeping infants. Use the chart for an individual baby or list several babies – if you
check them all together. Write the name of each baby checked in the Name column. Staff doing the checking must note the times and put their initial.
Check the Sleep Position and Code Letter: B=Back; Si=Side; T=Tummy (Stomach) to indicate the baby’s sleep position when FIRST placed to
sleep and when checked. Write additional comments describing the infant’s sleep such as “rolled over for the first time, ” in the comment space
provided.
Date:
Position when
1
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3
4
5
Time Checked
Time Checked
Time Checked
Time Checked
Time Checked
Baby’s Name:
Sleep Time:
FIRST placed
& Initial:
& Initial:
& Initial:
& Initial:
& Initial:
Initial:
to sleep:
Baby’s Position:
Baby’s Position:
Baby’s Position:
Baby’s Position:
Baby’s Position:
□ Back
Name:
Date: _______
Time:__________
Time:____________
Time:___________
Time:____________
Time:___________
□ S
_________________
Time: _______
ide
Initial: _________
Initial: ___________
Initial: __________
Initial: ___________
Initial: __________
□ Tummy
□
B
□
Si
□
T
□ B □ Si □ T
□
B
□
Si
□
T
□ B □ Si □ T
□
B
□
Si
□
T
Initial: _______
Comments:
□ Back
Name:
Date: _______
Time:__________
Time:____________
Time:___________
Time:____________
Time:___________
□ S
_________________
Time: _______
ide
Initial: _________
Initial: ___________
Initial: __________
Initial: ___________
Initial: __________
□ Tummy
□
B
□
Si
□
T
□ B □ Si □ T
□
B
□
Si
□
T
□ B □ Si □ T
□
B
□
Si
□
T
Initial: _______
Comments:
□ Back
Name:
Date: _______
Time:__________
Time:____________
Time:___________
Time:____________
Time:___________
□ S
_________________
Time: _______
ide
Initial: _________
Initial: ___________
Initial: __________
Initial: ___________
Initial: __________
□ Tummy
□
B
□
Si
□
T
□ B □ Si □ T
□
B
□
Si
□
T
□ B □ Si □ T
□
B
□
Si
□
T
Initial: _______
Comments:
□ Back
Name:
Date: _______
Time:__________
Time:____________
Time:___________
Time:____________
Time:___________
□ S
_________________
Time: _______
ide
Initial: _________
Initial: ___________
Initial: __________
Initial: ___________
Initial: __________
□ Tummy
□
B
□
Si
□
T
□ B □ Si □ T
□
B
□
Si
□
T
□ B □ Si □ T
□
B
□
Si
□
T
Initial: _______
Comments:
Page _____ of _____
Sample by: North Carolina Healthy Start Foundation 6/04
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