Link to Educarer HOME

AHT  VIDEO
VIEWING  CONFIRMATION

Minnesota Statutes § 245A.40 and § 245A.50 require that license holders, staff persons, caregivers and helpers who assist in the care of infants in a licensed program must document their training on AHT / SBS.

NOTE: Indicate below the viewing date and title of the Abusive Head Trauma video(s) that you viewed. AHT training (course and video) is required every year.

I, the undersigned, hereby confirm the following:

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

[   ] License holder

[   ] Staff person; caregiver; helper for License holder

working in which of the following kind of care situations:

[   ] Day Care  or   [   ] Foster Care  or   [   ] Adoption

__________________________________________________________________

PRINT License holder's name or Program's name


__________________________________________________________________

PRINT Address of License holder or Program's address


On ___________________________  I viewed the MN Dept. of Health's AHT video(s) named below.

Date of viewing

[   ]  Video # 1: What is the Period of PURPLE Crying?

[   ]  Video # 2: MN Hospital Association's Shaken Baby Syndrome

[   ]  Video # 3: 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 # 4 as shown below.

[   ]  Video # 4: (Optional) Shaken Baby - by Epilepsy Foundation of Central Florida.

My signature confirms I viewed the video(s) check marked above and have requested a copy of this confirmation be made part of the License holder's file.

__________________________________________________________________

Video Viewer's Name


__________________________________________________________________

Video Viewer's Signature


_______________________________

Date signed


CAREGIVER SHOULD ALSO KEEP A COPY FOR HIS OR HER PERSONAL FILES!