INDIVIDUAL INFANT SLEEPING PLAN

State of California - Health and Human Services Agency
California Department of Social Services
INDIVIDUAL INFANT SLEEPING PLAN
Date of plan:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SECTION A: INFANT'S INFORMATION
Infant's Name
Gender
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Authorized Representative's Name (Primary Contact)
Phone Number
Format: (000) 000-0000.
Authorized Representative's Name (Secondary Contact)
Phone Number
Format: (000) 000-0000.
SECTION B: SLEEPING ENVIRONMENT INFORMATION
At home, the infant sleeps in:

Other
What are the Infant's usual sleeping hours?

Hour Minutes

AM/PM Option

Until

Hour Minutes

AM/PM Option
What is the infant's average length of the infant's nap(s) during the day time?
minutes
hours
Does the infant use a pacifier?
If yes, brand:
SECTION C: INFANT'S ABILITY TO ROLL
My child First Name Last Name is able to roll from their back to their stomach and stomach to their back beginning .
Authorized Representative Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SECTION D: INFANT'S ABILITY TO ROLL IN CHILD CARE
Provider observed the infant is capable of rolling from their back to their stomach and stomach to their back.
Provider Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Authorized Representative Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
(To be completed no later than the next business day following observation)
LIC 9227 (8/20) Confidential
Page 1 of 2

INDIVIDUAL INFANT SLEEPING PLAN

SECTION A: INFANT'S INFORMATION

SECTION B: SLEEPING ENVIRONMENT INFORMATION

SECTION C: INFANT'S ABILITY TO ROLL

SECTION D: INFANT'S ABILITY TO ROLL IN CHILD CARE

SECTION E: MEDICAL EXEMPTION