MN DHS Parent Directive for Alternative Infant Sleep Position- Requires Health Care Provider Signature

MN DHS Parent Directive for Alternative Infant Sleep Position
This form must be signed with a Doctor's signature on Page 2. Below are the steps that need to be completed before this form can be submitted to Little Stars.
- Step 1- Fill in the required information on the form
- Step 2- Click "Preview PDF" to ensure information is accurate
- Step 3- Click "Generate Form". A copy of the form will be sent to the email address entered.
- Step 4- Print the form
- Step 5- Sign and date the form
- Step 6- Upload the completed form by visiting the secure upload here https://oriforms.jotform.com/231338605709963?jumpToPage=8
Parent Directive for Alternative Infant Sleep Position*
I understand that back sleeping is recommended and is safest for babies. I am directing an alternative position for this infant for the reason(s) stated below. By signing this form, I acknowledge that I am directing only an alternative sleep position and that the infant must always be placed in an approved crib to sleep.
Child Name*

First NameLast Name
Select One*

Place this infant on his/her STOMACH for sleep periods (not recommended)Place this infant on his/her SIDE for sleep periods (not recommended)
Medical reason for alternative sleep position*
Attach information of necessary

Cancelof
Expected duration of need for alternate sleep position: *
List the date the infant will be re-evaluated for the need for an alternative sleep position by a physician, advanced practice registered nurse, or physician assistant: *

MonthDayYear
Date
Licensed providers must place an infant in a crib to sleep. Car seats, swings, couches, the floor on a blanket, etc. are not acceptable as an alternative sleep position.)
Signatures

I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Email*
example@example.com
Parent/Guardian Signature*

Clear
Date of Signature

MonthDayYear
Date
I have clicked "Preview PDF" and reviewed my form for accuracy*

YesNo
Please verify that you are human*
Should be Empty:

MN DHS Parent Directive for Alternative Infant Sleep Position

Signatures