2013 Safe Sleep Audit Survey

1. Safe Sleep Audit Tool

1. What month are you doing this audit?
2. What unit is the baby on?
3. How old is the baby (use their birthdate not gestational age)?
4. Is the baby sleeping in:
5. Is there a medical exception for sleeping on the back based on diagnosis or treatment?
6. What is the baby's sleep position?
7. Is the head of the bed flat?
8. Are there any objects in the infant's sleep area during sleep?(Select all that apply)
9. Are there any extra linens that are loose in the sleep area? (Select all that apply)
10. What is the baby wearing or is bundling used? (select all that apply.)
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.
12. Is this baby in a safe sleep environment?
13. Was feedback given to staff?
14. What other questions do you have?
15. This was entered into Survey Monkey.
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