Baby Sleep Chart Template Page 2
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1
2
3Sleep Chart
Month: ____________________
Year: _________________
Date:
Position when
1
2
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:
□ 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:
Instructions: 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 in the comment space provided.
Page _____ of _____
Sample by: North Carolina Healthy Start Foundation 6/04
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