SHAKEN BABY VIDEO VIEWING CONFIRMATION

NOTE: Viewing an SBS approved video is an annual requirement.
Indicate below the viewing date and title of the "approved" Shaken Baby Syndrome video(s) that you viewed. SBS training (course and video) is required every five (5) years.

I, the undersigned, hereby confirm the following:

I am a . . .   (Please check appropriate box below)

[   ] Licenseholder

[   ] Staff person; caregiver; helper for Licenseholder

working in which of the following kind of care situations:

[   ]  Day Care    or    [   ]  Foster Care

__________________________________________________________________ PRINT Licenseholder's name or Program's name __________________________________________________________________ PRINT Address of Licenseholder or Program's address On ___________________________  I viewed the MN Dept. of Health's approved SBS video(s) named below. Date of viewing [   ]  Video # 1: MN Hospital Association's Shaken Baby Syndrome [   ]  Video # 2: Never Shake a Baby: What Caregivers and Parents Need to Know! OPTIONAL: If the below box is checked, then I also viewed the OPTIONAL Video # 3 as shown below. [  ]  Video # 3: (Optional) Shaken Baby - by Epilepsy Foundation of Central Florida. My signature confirms I viewed the videos check marked above and have requested a copy of this confirmation be made part of the Licenseholder's file. __________________________________________________________________ Video Viewer's Name __________________________________________________________________ Video Viewer's Signature _______________________________ Date signed CAREGIVER SHOULD ALSO KEEP A COPY FOR HIS OR HER PERSONAL FILES!