Exit this survey 2013 Safe Sleep Audit Survey 1. Safe Sleep Audit Tool Question Title * 1. What month are you doing this audit? January February March April May June July August September October November December Question Title * 2. What unit is the baby on? Center 3 NICU NPCU Center 7 Center 8/EMU East 5 HOT East 8 West 3 West 4 West 5 West 9 West 10 West 11 Audited in OR or PACU Fox Valley NICU Fox Valley Peds Question Title * 3. How old is the baby (use their birthdate not gestational age)? less than 2 months 2-4 months 5-8 months 9-12 months Question Title * 4. Is the baby sleeping in: Bassinet Crib Warmer Being held Parent cot/bed Question Title * 5. Is there a medical exception for sleeping on the back based on diagnosis or treatment? no yes if yes,list condition or diagnosis Question Title * 6. What is the baby's sleep position? back(supine) side abdomen(prone) Question Title * 7. Is the head of the bed flat? yes no Question Title * 8. Are there any objects in the infant's sleep area during sleep?(Select all that apply) no wipes or diapers, or other care items. stuffed animals unsecured toys pillow Other (please specify) Question Title * 9. Are there any extra linens that are loose in the sleep area? (Select all that apply) no balloon blanket under the baby and not tucked in burp cloth loose covering blankets Other (please specify) Question Title * 10. What is the baby wearing or is bundling used? (select all that apply.) bundled with blanket securely. sleep sack pajamas/gown fleece blanket or fleece sleep sack is used hat unable to see Other (please specify) Question Title * 11. Is a developmental device (frog,bendy bumper,etc) being used properly? They are not to be placed on top of babies or to hold a pacifier in the mouth. Skip this question if there is not one in use. yes no Other (please specify improper use) Question Title * 12. Is this baby in a safe sleep environment? yes no not sure If not sure, what is your question? Question Title * 13. Was feedback given to staff? yes no Question Title * 14. What other questions do you have? Question Title * 15. This was entered into Survey Monkey. yes no Next