North Carolina child care law requires facilities to place all infants on their backs to sleep. When the infant's primary health care professional advises an alternative sleep position or a wedge for medical reasons, this waiver documents the reason, the recommended position, wedge directions and effective dates, and the parent authorizes the facility to follow it.
The parent completes the child and contact details and signs the release; the child's primary health care professional, a physician, nurse practitioner or physician assistant, completes and signs the medical section; a facility representative signs last.
Download the current version from the source each time; forms change without notice.
ITS-SIDS Alternative Sleep Position/Use of Wedge Health Care Professional Waiver
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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The form must be completed by a physician, nurse practitioner or physician assistant, and the medical section is for the child's primary health care professional, who adds practice details, the medical reason, the recommended position and the effective dates.
The health care professional enters effective dates from and to, so the waiver covers only that period. The facility keeps the waiver in the child's record for as long as the child is enrolled at the center.
Yes. The Division of Child Development and Early Education posts a Spanish version of the alternative sleep position request alongside the English waiver on its provider documents and forms page.