Child Passenger Safety Checklist

• Document No.

• Child passenger safety checklist

• Baylor Scott and White McKinney

• Conducted on

  Date

• Prepared by

• I understand that, even though Baylor Scott and White Medical Center McKinney is providing me information about keeping my child safe while riding in a car, I understand that it is my sole responsibility to read and understand the directions for the car safety equipment I use for my child and to determine the suitability of the car safety equipment for my child. I know that it is important to become familiar with the proper way to install and operate the car safety equipment I use for my child and that it is my sole responsibility to educate myself regarding its proper installation and use. I acknowledge that neither Baylor Scott and White Medical Center McKinney nor any of its staff members have any special knowledge or expertise regarding the specific operation, design or features of any particular car safety equipment, that I may not rely upon Baylor Scott and White Medical Center McKinney or any such agents, employees or representatives for guidance in the installation or use thereof and that Baylor Scott and White Medical Center McKinney does not assume any responsibility or undertake any duty of care for the health and safety of my child while using car safety equipment. Baylor Scott and White Health McKinney and its employees are not responsible for any damage that may occur while installing child safety equipment.

  Sign

• Date/time of signature

  Date

Name, Address, Phone number, Vehicle Make/Model

• Driver License information

  Media

• Vehicle Make/Model

  Media

About the child & CSS/Restraint

• Child Present

  Yes

  No

  N/A

• Expectant Mom

  Yes

  No

  N/A

• Seat history known?

  Yes

  No

  N/A

• CSS involved in crash?

  Yes

  No

  N/A

• Child location within the vehicle?

  Select Passenger Center Driver 3rd row P 3rd row C 3rd row D

  • Passenger
  • Center
  • Driver
  • 3rd row P
  • 3rd row C
  • 3rd row D

• CSS Mfg, Model Number, Mfg Date

  Media

• Car seat type

  Infant

  Convertible

  Booster

• Delivering at BSWH-McKinney?

  Yes

  No

  N/A

• Parents knowledgeable of CSS installation?

  Yes

  No

  N/A

• Car seat installed?

  Yes

  No

  N/A

• Car seat installed using anchors?

  Yes

  No

  N/A

• Installed correctly?

  Yes

  No

  N/A

• Car seat installed using seatbelt?

  Yes

  No

  N/A

• Installed correctly?

  Yes

  No

  N/A

• No unapproved items are located on car seat? (select yes if no items are present)

  Yes

  No

  N/A

• The car seat doesn't move more than 1 inch (if it doesn't, select yes)

  Yes

  No

  N/A

• Harness correct

  Yes

  No

  N/A

• Angle correct

  Yes

  No

  N/A

• Registration card filled out and sent it

  Yes

  No

  N/A