Overnight Sleep Record–Client Form

All forms of this field must be filled out for every overnight shift. Caregivers failing to complete sleep record for each shift by the end of the business day after the shift will no longer be scheduled for overnights.

Please fill in every item.

Name:

Client First Name:

Date of shift:

Start time:

End time:

This overnight shift was:
SLEEPOVER (5 hrs uninterrupted sleep in private room)


HOURLY/SLEEPLESS (does not meet sleepover criteria)

Client went to bed at (time):

DURING THE NIGHT:
Awakened at (time):

Back to sleep at (time):

Awakened at:


Back to sleep at:

Awakened at:

Back to sleep at:

Awakened at:

Back to sleep at:

Awakened at:

Back to sleep at:

Client was awake for the day at (time):

If client was up and down more than 5 times, and this is unusual for this client, please call the office in the morning. If an overnight shift was scheduled to be SLEEPOVER and the client’s needs caused it to be HOURLY/SLEEPLESS you MUST call the office the first thing in the morning to report this. Submitting this form does not substitute for the call.

Click here when complete.