Child Passenger Safety Inspection Form

• Location

• Technician Name

• Conducted on

  Date

• Document No.

Participant Information

• Name

• Address (Street/City/State/Zip)

• Phone number

• Email address

Vehicle Information

• Vehicle Make

  Select Acura Audi BMW Buick Cadillac Chevrolet Chrysler Dodge Ford GMC Honda Hummer Hyundai Infiniti Isuzu Jaguar Jeep Kia Lexus Lincoln Mazda Mercedes-Benz Mercury Mitsubishi Nissan Oldsmobile Pontiac Saab Saturn Subaru Suzuki Toyota Volkswagon Volvo

  • Acura
  • Audi
  • BMW
  • Buick
  • Cadillac
  • Chevrolet
  • Chrysler
  • Dodge
  • Ford
  • GMC
  • Honda
  • Hummer
  • Hyundai
  • Infiniti
  • Isuzu
  • Jaguar
  • Jeep
  • Kia
  • Lexus
  • Lincoln
  • Mazda
  • Mercedes-Benz
  • Mercury
  • Mitsubishi
  • Nissan
  • Oldsmobile
  • Pontiac
  • Saab
  • Saturn
  • Subaru
  • Suzuki
  • Toyota
  • Volkswagon
  • Volvo

• Vehicle Model

• Vehicle Year

  Select 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995

  • 2015
  • 2014
  • 2013
  • 2012
  • 2011
  • 2010
  • 2009
  • 2008
  • 2007
  • 2006
  • 2005
  • 2004
  • 2003
  • 2002
  • 2001
  • 2000
  • 1999
  • 1998
  • 1997
  • 1996
  • 1995

• Odometer

Children Information

• Child 1 Name

• Child 1 Age

  Select Unborn newborn 1 month old 2 month old 3 month old 4 month old 5 month old 6 month old 7 month old 8 month old 9 month old 10 month old 11 month old 12 month old 13 month old 14 month old 15 month old 16 month old 17 month old 18-23 month old 2 year old 3 year old 4 year old 5 year old 6 year old 7 year old 8 year old 9 year old 10 year old 11 year old 12 year old

  • Unborn
  • newborn
  • 1 month old
  • 2 month old
  • 3 month old
  • 4 month old
  • 5 month old
  • 6 month old
  • 7 month old
  • 8 month old
  • 9 month old
  • 10 month old
  • 11 month old
  • 12 month old
  • 13 month old
  • 14 month old
  • 15 month old
  • 16 month old
  • 17 month old
  • 18-23 month old
  • 2 year old
  • 3 year old
  • 4 year old
  • 5 year old
  • 6 year old
  • 7 year old
  • 8 year old
  • 9 year old
  • 10 year old
  • 11 year old
  • 12 year old

• Child 1 Weight (pounds)

• Child 1 Height (inches)

• Child 2?

  Yes

  No

• Child 2 Name

• Child 2 Age

  Select Unborn newborn 1 month old 2 month old 3 month old 4 month old 5 month old 6 month old 7 month old 8 month old 9 month old 10 month old 11 month old 12 month old 13 month old 14 month old 15 month old 16 month old 17 month old 18-23 month old 2 year old 3 year old 4 year old 5 year old 6 year old 7 year old 8 year old 9 year old 10 year old 11 year old 12 year old

  • Unborn
  • newborn
  • 1 month old
  • 2 month old
  • 3 month old
  • 4 month old
  • 5 month old
  • 6 month old
  • 7 month old
  • 8 month old
  • 9 month old
  • 10 month old
  • 11 month old
  • 12 month old
  • 13 month old
  • 14 month old
  • 15 month old
  • 16 month old
  • 17 month old
  • 18-23 month old
  • 2 year old
  • 3 year old
  • 4 year old
  • 5 year old
  • 6 year old
  • 7 year old
  • 8 year old
  • 9 year old
  • 10 year old
  • 11 year old
  • 12 year old

• Child 2 Weight (pounds)

• Child 2 Height (inches)

• Child 3?

  Yes

  No

• Child 3 Name

• Child 3 Age

  Select Unborn newborn 1 month old 2 month old 3 month old 4 month old 5 month old 6 month old 7 month old 8 month old 9 month old 10 month old 11 month old 12 month old 13 month old 14 month old 15 month old 16 month old 17 month old 18-23 month old 2 year old 3 year old 4 year old 5 year old 6 year old 7 year old 8 year old 9 year old 10 year old 11 year old 12 year old

  • Unborn
  • newborn
  • 1 month old
  • 2 month old
  • 3 month old
  • 4 month old
  • 5 month old
  • 6 month old
  • 7 month old
  • 8 month old
  • 9 month old
  • 10 month old
  • 11 month old
  • 12 month old
  • 13 month old
  • 14 month old
  • 15 month old
  • 16 month old
  • 17 month old
  • 18-23 month old
  • 2 year old
  • 3 year old
  • 4 year old
  • 5 year old
  • 6 year old
  • 7 year old
  • 8 year old
  • 9 year old
  • 10 year old
  • 11 year old
  • 12 year old

• Child 3 Weight (pounds)

• Child 3 Height (inches)

Agreement

• I understand that the sole purpose of this check up form is to help reduce the incidence of improper installation and use of child safety seats. This inspection is being provided as a free service to me. I understand that the technician will provide me with best practices and accurate information but the final decision is up to me, the caregiver. I understand that the technician may not assist me in breaking California's child restraint laws. I understand that this technician cannot fully evaluate the quality, safety, or condition of my child safety seat or any component of my vehicle. This includes the seats, safety belts, LATCH and airbags. This assessment cannot guarantee my child's safety in a vehicle collision. However, I understand that a properly used child safety seat can reduce fatal injury by 71% and that it is important to read both my vehicle and safety seat instruction manuals.

• Signature

  Sign

• Child 1 Name

• CRS Type

  Select Harnessed Seat Base-Only Booster Safety Belt Integrated Vest

  • Harnessed Seat
  • Base-Only
  • Booster
  • Safety Belt
  • Integrated
  • Vest

• Is the child the correct age/weight/height for this seat?

  Yes

  No

• Is the child present?

  Yes

  No

• Is the child sitting up, not slouching?

  Yes

  No

• Is the lap belt snug and low on the hips?

  Yes

  No

• Is the shoulder belt properly positioned?

  Yes

  No

• Is the buckle latched securely?

  Yes

  No

• Is it a high back or backless booster?

  High Back Booster

  Backless booster

• Is the seat attached with LATCH?

  Yes

  No

• Is LATCH use acceptable for this booster?

  Yes

  No

• Is the top tether strap used?

  Yes

  No

  No Tether

• Is it used correctly?

  Yes

  No

Current Booster Information

• Is booster information missing?

  Yes

  No

• Booster manufacturer

  Select Britax BubbleBum Chicco Clek Combi Cosco Cybex Diono Evenflo The First Years GOBOOSTER Graco Harmony Kiddy Maxi-Cosi Peg Perego Recaro Safety 1st

  • Britax
  • BubbleBum
  • Chicco
  • Clek
  • Combi
  • Cosco
  • Cybex
  • Diono
  • Evenflo
  • The First Years
  • GOBOOSTER
  • Graco
  • Harmony
  • Kiddy
  • Maxi-Cosi
  • Peg Perego
  • Recaro
  • Safety 1st

• Booster model name

• Booster model number

• Date of manufacture

  Date

• Is the booster expired?

  Yes

  No

• Is the participant the original owner of the booster?

  Yes

  No

• Has the booster been in a crash?

  Yes

  No

• Was the registration card sent in?

  Yes

  No

• With the participant's current address?

  Yes

  No

• NHTSA Recall List
  http://www-odi.nhtsa.dot.gov/recalls/childseat.cfm?MfgID=All

• Is there a recall on this booster?

  Yes

  No

• Has the recall been repaired?

  Yes

  No

• Is this a US certified (FMVSS 213) booster?

  Yes

  No

• Did the child get a new seat at the event?

  Yes

  No

• New seat manufacturer

  Yes

  No

  N/A

• New seat model name

• New seat model number

• New seat date of manufacture

  Date

• Who provided the seat?

  Participant

  Clinic

• Who registered the seat?

  Participant

  Clinic

• Final Install with?

  LATCH

  Seat Belt

• Used the top tether?

  Yes

  No

• Draw the final location of the seat (X). Use a M if the seat was moved. D for the driver.

  Drawing

• Photograph if desired.

  Media

• Final comments on installation

• Is the child the correct age/weight/height for this seat?

  Yes

  No

• Is the base installed on arrival?

  Yes

  No

• Is the base attached with LATCH?

  Yes

  No

• Is the LATCH system holding the base tightly (1" test)?

  Yes

  No

• Is the LATCH used correctly?

  Yes

  No

• Is the base attached with the safety belt?

  Yes

  No

• Is the belt holding the base tightly (1" test)?

  Yes

  No

• Is the belt routed through the base correctly?

  Yes

  No

• What type of belt was used?

  Lap/shoulder belt

  Lap only belt

  Other

• What type of retractor was used?

  Switchable/locked mode

  Switchable/unlocked

  ELR

  ALR

  None

• What type of latchplate was used?

  Freesliding

  Locking

  Fixed/sewn

  Switchable/locked

  Switchable/unlocked

• Is a locking clip needed?

  Yes

  No

• Is it used?

  Yes

  No

• Is it used correctly?

  Yes

  No

• Is the seat belt used correctly?

  Yes

  No

• Is the base attached with both LATCH and belt?

  Yes

  No

Current Seat Information

• Is the seat information missing?

  Yes

  No

• Base manufacturer

  Select Baby Trend Britax Chicco Combi Cosco Cybex Dream on Me Eddie Bauer Evenflo The First Years Graco Maxi-Cosi Orbit Peg/Perego Recaro Safety 1st Summer UPPAbaby

  • Baby Trend
  • Britax
  • Chicco
  • Combi
  • Cosco
  • Cybex
  • Dream on Me
  • Eddie Bauer
  • Evenflo
  • The First Years
  • Graco
  • Maxi-Cosi
  • Orbit
  • Peg/Perego
  • Recaro
  • Safety 1st
  • Summer
  • UPPAbaby

• Base model name

• Base model number

• Date of manufacture

  Date

• Is the base expired?

  Yes

  No

• Is the participant the original owner of the base?

  Yes

  No

• Has the base been in a crash?

  Yes

  No

• Was the registration card sent in?

  Yes

  No

• With the participant's current address?

  Yes

  No

• NHTSA Recall List
  http://www-odi.nhtsa.dot.gov/recalls/childseat.cfm?MfgID=All

• Is there a recall on this base?

  Yes

  No

• Has the recall been repaired?

  Yes

  No

• Is this a US certified (FMVSS 213) base?

  Yes

  No

• Did the child get a new seat at the event?

  Yes

  No

• New seat manufacturer

• New seat model name

• New seat model number

• New seat date of manufacture

  Date

• Who provided the seat?

  Participant

  Clinic

• Who registered the seat?

  Participant

  Clinic

• Final Install with?

  LATCH

  Seat Belt

• Used the top tether?

  Yes

  No

• Draw the final location of the seat (X). Use a M if the seat was moved. D for the driver.

  Drawing

• Photograph if desired.

  Media

• Final comments on installation

• Is the seat installed on arrival?

  Yes

  No

• Is the child present?

  Yes

  No

• What type of seat is it?

  Infant-only

  Convertible/rear facing

  Convertible/forward facing

  Combo - ff only

  Car Bed

• Is the seat installed with a base?

  Yes

  No

• Does the seat have a five-point harness?

  Yes

  No

• Is the handle in the proper position?

  Yes

  No

• Is the seat reclined properly for the age of the child?

  Yes

  No

• Is the seat reclined properly for the age of the child?

  Yes

  No

• Is the seat properly upright?

  Yes

  No

• Is the child the correct age/weight/height for this seat?

  Yes

  No

• Is this seat facing the appropriate direction for this child?

  Yes

  No

• Is the harness snug?

  Yes

  No

• Is the harness in the correct slots?

  Yes

  No

• Has the harness retainer clip been used properly?

  Yes

  No

• Is the seat attached with LATCH?

  Yes

  No

• Is the LATCH system holding the seat tightly (1" test)?

  Yes

  No

• Is the LATCH used correctly?

  Yes

  No

• Is the seat attached with the safety belt?

  Yes

  No

• Is the belt holding the seat tightly (1" test)?

  Yes

  No

• Is the belt routed through the seat correctly?

  Yes

  No

• What type of belt was used?

  Lap/shoulder belt

  Lap only belt

  Other

• What type of retractor was used?

  Switchable/locked mode

  Switchable/unlocked

  ELR

  ALR

  None

• What type of latchplate was used?

  Freesliding

  Locking

  Fixed/sewn

  Switchable/locked

  Switchable/unlocked

• Is a locking clip needed?

  Yes

  No

• Is it used?

  Yes

  No

• Is it used correctly?

  Yes

  No

• Are any safety belt after-market products used?

  Yes

  No

• Is the seat belt used correctly?

  Yes

  No

• Is the seat attached with both LATCH and belt?

  Yes

  No

• Is the top tether strap used?

  Yes

  No

  No Tether

• Is it used correctly?

  Yes

  No

Current Seat Information

• Is the seat information missing?

  Yes

  No

• Seat manufacturer

  Select Angel Guard Baby Trend Britax Chicco Clek Combi Convaid Cosco Cybex Diono/Sunshine Kids Dream on Me Eddie Bauer Evenflo The First Years Graco Harmony Kiddy World KIDSEmbrace Orbit Maxi Cosi Merritt Peg/Perego Patterson Recaro Safety 1st SnugSeat Special Tomato Summer UPPAbaby

  • Angel Guard
  • Baby Trend
  • Britax
  • Chicco
  • Clek
  • Combi
  • Convaid
  • Cosco
  • Cybex
  • Diono/Sunshine Kids
  • Dream on Me
  • Eddie Bauer
  • Evenflo
  • The First Years
  • Graco
  • Harmony
  • Kiddy World
  • KIDSEmbrace
  • Orbit
  • Maxi Cosi
  • Merritt
  • Peg/Perego
  • Patterson
  • Recaro
  • Safety 1st
  • SnugSeat
  • Special Tomato
  • Summer
  • UPPAbaby

• Seat model name

• Seat model number

• Date of manufacture

  Date

• Is the seat expired?

  Yes

  No

• Is the participant the original owner of the seat?

  Yes

  No

• Has the seat been in a crash?

  Yes

  No

• Was the registration card sent in?

  Yes

  No

• With the participant's current address?

  Yes

  No

• NHTSA Recall List
  http://www-odi.nhtsa.dot.gov/recalls/childseat.cfm?MfgID=All

• Is there a recall on this seat?

  Yes

  No

• Has the recall been repaired?

  Yes

  No

• Is this a US certified (FMVSS 213) seat?

  Yes

  No

• Did the child get a new seat at the event?

  Yes

  No

• New seat manufacturer

• New seat model name

• New seat model number

• New seat date of manufacture

  Date

• Who provided the seat?

  Participant

  Clinic

• Who registered the seat?

  Participant

  Clinic

• Final Install with?

  LATCH

  Seat Belt

• Used the top tether?

  Yes

  No

• Draw the final location of the seat (X). Use a M if the seat was moved. D for the driver.

  Drawing

• Photograph if desired.

  Media

• Final comments on installation

• What type of seat is it?

  Infant-only

  Convertible/rear facing

  Convertible/forward facing

  Combo - ff only

  Car Bed

• Is the seat installed with a base?

  Yes

  No

• Does the seat have a five-point harness?

  Yes

  No

• Is the handle in the proper position?

  Yes

  No

• Is the seat reclined properly for the age of the child?

  Yes

  No

• Is the seat reclined properly for the age of the child?

  Yes

  No

• Is the seat properly upright?

  Yes

  No

• Is the child the correct age/weight/height for this seat?

  Yes

  No

• Is this seat facing the appropriate direction for this child?

  Yes

  No

• Is the seat attached with LATCH?

  Yes

  No

• Is the LATCH system holding the seat tightly (1" test)?

  Yes

  No

• Is the LATCH used correctly?

  Yes

  No

• Is the seat attached with the safety belt?

  Yes

  No

• Is the belt holding the seat tightly (1" test)?

  Yes

  No

• Is the belt routed through the seat correctly?

  Yes

  No

• What type of belt was used?

  Lap/shoulder belt

  Lap only belt

  Other

• What type of retractor was used?

  Switchable/locked mode

  Switchable/unlocked

  ELR

  ALR

  None

• What type of latchplate was used?

  Freesliding

  Locking

  Fixed/sewn

  Switchable/locked

  Switchable/unlocked

• Is a locking clip needed?

  Yes

  No

• Is it used?

  Yes

  No

• Is it used correctly?

  Yes

  No

• Are any safety belt after-market products used?

  Yes

  No

• Is the seat belt used correctly?

  Yes

  No

• Is the seat attached with both LATCH and belt?

  Yes

  No

• Is the top tether strap used?

  Yes

  No

  No Tether

• Is it used correctly?

  Yes

  No

Current Seat Information

• Is the seat information missing?

  Yes

  No

• Seat manufacturer

  Select Angel Guard Baby Trend Britax Chicco Clek Combi Convaid Cosco Cybex Diono/Sunshine Kids Dream on Me Eddie Bauer Evenflo The First Years Graco Harmony Kiddy World KIDSEmbrace Orbit Maxi Cosi Merritt Peg/Perego Patterson Recaro Safety 1st SnugSeat Special Tomato Summer UPPAbaby

  • Angel Guard
  • Baby Trend
  • Britax
  • Chicco
  • Clek
  • Combi
  • Convaid
  • Cosco
  • Cybex
  • Diono/Sunshine Kids
  • Dream on Me
  • Eddie Bauer
  • Evenflo
  • The First Years
  • Graco
  • Harmony
  • Kiddy World
  • KIDSEmbrace
  • Orbit
  • Maxi Cosi
  • Merritt
  • Peg/Perego
  • Patterson
  • Recaro
  • Safety 1st
  • SnugSeat
  • Special Tomato
  • Summer
  • UPPAbaby

• Seat model name

• Seat model number

• Date of manufacture

  Date

• Is the seat expired?

  Yes

  No

• Is the participant the original owner of the seat?

  Yes

  No

• Has the seat been in a crash?

  Yes

  No

• Was the registration card sent in?

  Yes

  No

• With the participant's current address?

  Yes

  No

• NHTSA Recall List
  http://www-odi.nhtsa.dot.gov/recalls/childseat.cfm?MfgID=All

• Is there a recall on this seat?

  Yes

  No

• Has the recall been repaired?

  Yes

  No

• Is this a US certified (FMVSS 213) seat?

  Yes

  No

• Did the child get a new seat at the event?

  Yes

  No

• New seat manufacturer

• New seat model name

• New seat model number

• New seat date of manufacture

  Date

• Who provided the seat?

  Participant

  Clinic

• Who registered the seat?

  Participant

  Clinic

• Final Install with?

  LATCH

  Seat Belt

• Used the top tether?

  Yes

  No

• Draw the final location of the seat (X). Use a M if the seat was moved. D for the driver.

  Drawing

• Photograph if desired.

  Media

• Final comments on installation

• What type of seat is it?

  Infant-only

  Convertible/rear facing

  Convertible/forward facing

  Combo - ff only

  Car Bed

• Does the seat have a base?

  Yes

  No

• Does the seat have a five-point harness?

  Yes

  No

• Are any safety belt after-market products used?

  Yes

  No

• Is the child the correct age/weight/height for this seat?

  Yes

  No

Current Seat Information

• Is the seat information missing?

  Yes

  No

• Seat manufacturer

  Select Angel Guard Baby Trend Britax Chicco Clek Combi Convaid Cosco Cybex Diono/Sunshine Kids Dream on Me Eddie Bauer Evenflo The First Years Graco Harmony Kiddy World KIDSEmbrace Orbit Maxi Cosi Merritt Peg/Perego Patterson Recaro Safety 1st SnugSeat Special Tomato Summer UPPAbaby

  • Angel Guard
  • Baby Trend
  • Britax
  • Chicco
  • Clek
  • Combi
  • Convaid
  • Cosco
  • Cybex
  • Diono/Sunshine Kids
  • Dream on Me
  • Eddie Bauer
  • Evenflo
  • The First Years
  • Graco
  • Harmony
  • Kiddy World
  • KIDSEmbrace
  • Orbit
  • Maxi Cosi
  • Merritt
  • Peg/Perego
  • Patterson
  • Recaro
  • Safety 1st
  • SnugSeat
  • Special Tomato
  • Summer
  • UPPAbaby

• Seat model name

• Seat model number

• Date of manufacture

  Date

• Is the seat expired?

  Yes

  No

• Is the participant the original owner of the seat?

  Yes

  No

• Has the seat been in a crash?

  Yes

  No

• Was the registration card sent in?

  Yes

  No

• With the participant's current address?

  Yes

  No

• NHTSA Recall List
  http://www-odi.nhtsa.dot.gov/recalls/childseat.cfm?MfgID=All

• Is there a recall on this seat?

  Yes

  No

• Has the recall been repaired?

  Yes

  No

• Is this a US certified (FMVSS 213) seat?

  Yes

  No

• Did the child get a new seat at the event?

  Yes

  No

• New seat manufacturer

  Select Angel Guard Baby Trend Britax Chicco Clek Combi Convaid Cosco Cybex Diono/Sunshine Kids Dream on Me Eddie Bauer Evenflo The First Years Graco Harmony Kiddy World KIDSEmbrace Orbit Maxi Cosi Merritt Peg/Perego Patterson Recaro Safety 1st SnugSeat Special Tomato Summer UPPAbaby

  • Angel Guard
  • Baby Trend
  • Britax
  • Chicco
  • Clek
  • Combi
  • Convaid
  • Cosco
  • Cybex
  • Diono/Sunshine Kids
  • Dream on Me
  • Eddie Bauer
  • Evenflo
  • The First Years
  • Graco
  • Harmony
  • Kiddy World
  • KIDSEmbrace
  • Orbit
  • Maxi Cosi
  • Merritt
  • Peg/Perego
  • Patterson
  • Recaro
  • Safety 1st
  • SnugSeat
  • Special Tomato
  • Summer
  • UPPAbaby

• New seat model name

• New seat model number

• New seat date of manufacture

  Date

• Who provided the seat?

  Participant

  Clinic

• Who registered the seat?

  Participant

  Clinic

• Final Install with?

  LATCH

  Seat Belt

• Used the top tether?

  Yes

  No

• Draw the final location of the seat (X). Use a M if the seat was moved. D for the driver.

  Drawing

• Photograph if desired.

  Media

• Final comments on installation

• Step 1: Is the child sitting all the way back against the auto seat?

  Yes

  No

• Step 2: Are the child’s knees bending comfortably at the edge of the auto seat?

  Yes

  No

• Step 3: Does the belt cross the shoulder between the neck and arm?

  Yes

  No

• Step 4: Is the lap belt as low as possible, touching the thighs?

  Yes

  No

• Step 5: Does the child stay seated like this for the whole trip?

  Yes

  No

• Did the child get a new seat at the event?

  Yes

  No

• New seat manufacturer

  Select Angel Guard Baby Trend Britax Chicco Clek Combi Convaid Cosco Cybex Diono/Sunshine Kids Dream on Me Eddie Bauer Evenflo The First Years Graco Harmony Kiddy World KIDSEmbrace Orbit Maxi Cosi Merritt Peg/Perego Patterson Recaro Safety 1st SnugSeat Special Tomato Summer UPPAbaby

  • Angel Guard
  • Baby Trend
  • Britax
  • Chicco
  • Clek
  • Combi
  • Convaid
  • Cosco
  • Cybex
  • Diono/Sunshine Kids
  • Dream on Me
  • Eddie Bauer
  • Evenflo
  • The First Years
  • Graco
  • Harmony
  • Kiddy World
  • KIDSEmbrace
  • Orbit
  • Maxi Cosi
  • Merritt
  • Peg/Perego
  • Patterson
  • Recaro
  • Safety 1st
  • SnugSeat
  • Special Tomato
  • Summer
  • UPPAbaby

• New seat model name

• New seat model number

• New seat date of manufacture

  Date

• Who provided the seat?

  Participant

  Clinic

• Who registered the seat?

  Participant

  Clinic

• Final Install with?

  LATCH

  Seat Belt

• Used the top tether?

  Yes

  No

• Draw the final location of the seat (X). Use a M if the seat was moved. D for the driver.

  Drawing

• Photograph if desired.

  Media

• Final comments on installation

• Is the child the correct age/weight/height for this seat?

  Yes

  No

• Is the harness snug?

  Yes

  No

• Is the harness in the correct slots?

  Yes

  No

• Has the harness retainer clip been used properly?

  Yes

  No

• Did the child get a new seat at the event?

  Yes

  No

• New seat manufacturer

  Select Angel Guard Baby Trend Britax Chicco Clek Combi Convaid Cosco Cybex Diono/Sunshine Kids Dream on Me Eddie Bauer Evenflo The First Years Graco Harmony Kiddy World KIDSEmbrace Orbit Maxi Cosi Merritt Peg/Perego Patterson Recaro Safety 1st SnugSeat Special Tomato Summer UPPAbaby

  • Angel Guard
  • Baby Trend
  • Britax
  • Chicco
  • Clek
  • Combi
  • Convaid
  • Cosco
  • Cybex
  • Diono/Sunshine Kids
  • Dream on Me
  • Eddie Bauer
  • Evenflo
  • The First Years
  • Graco
  • Harmony
  • Kiddy World
  • KIDSEmbrace
  • Orbit
  • Maxi Cosi
  • Merritt
  • Peg/Perego
  • Patterson
  • Recaro
  • Safety 1st
  • SnugSeat
  • Special Tomato
  • Summer
  • UPPAbaby

• New seat model name

• New seat model number

• New seat date of manufacture

  Date

• Who provided the seat?

  Participant

  Clinic

• Who registered the seat?

  Participant

  Clinic

• Final Install with?

  LATCH

  Seat Belt

• Used the top tether?

  Yes

  No

• Draw the final location of the seat (X). Use a M if the seat was moved. D for the driver.

  Drawing

• Photograph if desired.

  Media

• Final comments on installation

• Is the child the correct age/weight/height for this vest?

  Yes

  No

• Is the vest attached with LATCH?

  Yes

  No

• Is the LATCH system holding the vest tightly?

  Yes

  No

• Is the LATCH used correctly?

  Yes

  No

• Is the vest attached with the safety belt?

  Yes

  No

• Is the belt holding the vest tightly?

  Yes

  No

• Is the belt routed through the vest correctly?

  Yes

  No

• What type of belt was used?

  Lap/shoulder belt

  Lap only belt

  Other

• What type of retractor was used?

  Switchable/locked mode

  Switchable/unlocked

  ELR

  ALR

  None

• What type of latchplate was used?

  Freesliding

  Locking

  Fixed/sewn

  Switchable/locked

  Switchable/unlocked

• Is a locking clip needed?

  Yes

  No

• Is it used?

  Yes

  No

• Is it used correctly?

  Yes

  No

• Are any safety belt after-market products used?

  Yes

  No

• Is the seat belt used correctly?

  Yes

  No

• Is the vest attached with both LATCH and belt?

  Yes

  No

• Is the top tether strap used?

  Yes

  No

  No Tether

• Is it used correctly?

  Yes

  No

Current Seat Information

• Is the vest information missing?

  Yes

  No

• Vest manufacturer

  E-Z-On

  Safe Traffic Systems

• Vest model name

• Vest model number

• Date of manufacture

  Date

• Is the vest expired?

  Yes

  No

• Is the participant the original owner of the vest?

  Yes

  No

• Has the vest been in a crash?

  Yes

  No

• Was the registration card sent in?

  Yes

  No

• With the participant's current address?

  Yes

  No

• NHTSA Recall List
  http://www-odi.nhtsa.dot.gov/recalls/childseat.cfm?MfgID=All

• Is there a recall on this vest?

  Yes

  No

• Has the recall been repaired?

  Yes

  No

• Is this a US certified (FMVSS 213) vest?

  Yes

  No

• Did the child get a new seat at the event?

  Yes

  No

• New seat manufacturer

• New seat model name

• New seat model number

• New seat date of manufacture

  Date

• Who provided the seat?

  Participant

  Clinic

• Who registered the seat?

  Participant

  Clinic

• Final Install with?

  LATCH

  Seat Belt

• Used the top tether?

  Yes

  No

• Draw the final location of the seat (X). Use a M if the seat was moved. D for the driver.

  Drawing

• Photograph if desired.

  Media

• Final comments on installation

• Child 1 Name

• CRS Type

  Select Harnessed Seat Base-Only Booster Safety Belt Integrated Vest

  • Harnessed Seat
  • Base-Only
  • Booster
  • Safety Belt
  • Integrated
  • Vest

• Is the child the correct age/weight/height for this seat?

  Yes

  No

• Is the child present?

  Yes

  No

• Is the child sitting up, not slouching?

  Yes

  No

• Is the lap belt snug and low on the hips?

  Yes

  No

• Is the shoulder belt properly positioned?

  Yes

  No

• Is the buckle latched securely?

  Yes

  No

• Is it a high back or backless booster?

  High Back Booster

  Backless booster

• Is the seat attached with LATCH?

  Yes

  No

• Is LATCH use acceptable for this booster?

  Yes

  No

• Is the top tether strap used?

  Yes

  No

  No Tether

• Is it used correctly?

  Yes

  No

Current Booster Information

• Is booster information missing?

  Yes

  No

• Booster manufacturer

  Select Britax BubbleBum Chicco Clek Combi Cosco Cybex Diono Evenflo The First Years GOBOOSTER Graco Harmony Kiddy Maxi-Cosi Peg Perego Recaro Safety 1st

  • Britax
  • BubbleBum
  • Chicco
  • Clek
  • Combi
  • Cosco
  • Cybex
  • Diono
  • Evenflo
  • The First Years
  • GOBOOSTER
  • Graco
  • Harmony
  • Kiddy
  • Maxi-Cosi
  • Peg Perego
  • Recaro
  • Safety 1st

• Booster model name

• Booster model number

• Date of manufacture

  Date

• Is the booster expired?

  Yes

  No

• Is the participant the original owner of the booster?

  Yes

  No

• Has the booster been in a crash?

  Yes

  No

• Was the registration card sent in?

  Yes

  No

• With the participant's current address?

  Yes

  No

• NHTSA Recall List
  http://www-odi.nhtsa.dot.gov/recalls/childseat.cfm?MfgID=All

• Is there a recall on this booster?

  Yes

  No

• Has the recall been repaired?

  Yes

  No

• Is this a US certified (FMVSS 213) booster?

  Yes

  No

• Did the child get a new seat at the event?

  Yes

  No

• New seat manufacturer

  Yes

  No

  N/A

• New seat model name

• New seat model number

• New seat date of manufacture

  Date

• Who provided the seat?

  Participant

  Clinic

• Who registered the seat?

  Participant

  Clinic

• Final Install with?

  LATCH

  Seat Belt

• Used the top tether?

  Yes

  No

• Draw the final location of the seat (X). Use a M if the seat was moved. D for the driver.

  Drawing

• Photograph if desired.

  Media

• Final comments on installation

• Is the child the correct age/weight/height for this seat?

  Yes

  No

• Is the base installed on arrival?

  Yes

  No

• Is the base attached with LATCH?

  Yes

  No

• Is the LATCH system holding the base tightly (1" test)?

  Yes

  No

• Is the LATCH used correctly?

  Yes

  No

• Is the base attached with the safety belt?

  Yes

  No

• Is the belt holding the base tightly (1" test)?

  Yes

  No

• Is the belt routed through the base correctly?

  Yes

  No

• What type of belt was used?

  Lap/shoulder belt

  Lap only belt

  Other

• What type of retractor was used?

  Switchable/locked mode

  Switchable/unlocked

  ELR

  ALR

  None

• What type of latchplate was used?

  Freesliding

  Locking

  Fixed/sewn

  Switchable/locked

  Switchable/unlocked

• Is a locking clip needed?

  Yes

  No

• Is it used?

  Yes

  No

• Is it used correctly?

  Yes

  No

• Is the seat belt used correctly?

  Yes

  No

• Is the base attached with both LATCH and belt?

  Yes

  No

Current Seat Information

• Is the seat information missing?

  Yes

  No

• Base manufacturer

  Select Baby Trend Britax Chicco Combi Cosco Cybex Dream on Me Eddie Bauer Evenflo The First Years Graco Maxi-Cosi Orbit Peg/Perego Recaro Safety 1st Summer UPPAbaby

  • Baby Trend
  • Britax
  • Chicco
  • Combi
  • Cosco
  • Cybex
  • Dream on Me
  • Eddie Bauer
  • Evenflo
  • The First Years
  • Graco
  • Maxi-Cosi
  • Orbit
  • Peg/Perego
  • Recaro
  • Safety 1st
  • Summer
  • UPPAbaby

• Base model name

• Base model number

• Date of manufacture

  Date

• Is the base expired?

  Yes

  No

• Is the participant the original owner of the base?

  Yes

  No

• Has the base been in a crash?

  Yes

  No

• Was the registration card sent in?

  Yes

  No

• With the participant's current address?

  Yes

  No

• NHTSA Recall List
  http://www-odi.nhtsa.dot.gov/recalls/childseat.cfm?MfgID=All

• Is there a recall on this base?

  Yes

  No

• Has the recall been repaired?

  Yes

  No

• Is this a US certified (FMVSS 213) base?

  Yes

  No

• Did the child get a new seat at the event?

  Yes

  No

• New seat manufacturer

• New seat model name

• New seat model number

• New seat date of manufacture

  Date

• Who provided the seat?

  Participant

  Clinic

• Who registered the seat?

  Participant

  Clinic

• Final Install with?

  LATCH

  Seat Belt

• Used the top tether?

  Yes

  No

• Draw the final location of the seat (X). Use a M if the seat was moved. D for the driver.

  Drawing

• Photograph if desired.

  Media

• Final comments on installation

• Is the seat installed on arrival?

  Yes

  No

• Is the child present?

  Yes

  No

• What type of seat is it?

  Infant-only

  Convertible/rear facing

  Convertible/forward facing

  Combo - ff only

  Car Bed

• Is the seat installed with a base?

  Yes

  No

• Does the seat have a five-point harness?

  Yes

  No

• Is the handle in the proper position?

  Yes

  No

• Is the seat reclined properly for the age of the child?

  Yes

  No

• Is the seat reclined properly for the age of the child?

  Yes

  No

• Is the seat properly upright?

  Yes

  No

• Is the child the correct age/weight/height for this seat?

  Yes

  No

• Is this seat facing the appropriate direction for this child?

  Yes

  No

• Is the harness snug?

  Yes

  No

• Is the harness in the correct slots?

  Yes

  No

• Has the harness retainer clip been used properly?

  Yes

  No

• Is the seat attached with LATCH?

  Yes

  No

• Is the LATCH system holding the seat tightly (1" test)?

  Yes

  No

• Is the LATCH used correctly?

  Yes

  No

• Is the seat attached with the safety belt?

  Yes

  No

• Is the belt holding the seat tightly (1" test)?

  Yes

  No

• Is the belt routed through the seat correctly?

  Yes

  No

• What type of belt was used?

  Lap/shoulder belt

  Lap only belt

  Other

• What type of retractor was used?

  Switchable/locked mode

  Switchable/unlocked

  ELR

  ALR

  None

• What type of latchplate was used?

  Freesliding

  Locking

  Fixed/sewn

  Switchable/locked

  Switchable/unlocked

• Is a locking clip needed?

  Yes

  No

• Is it used?

  Yes

  No

• Is it used correctly?

  Yes

  No

• Are any safety belt after-market products used?

  Yes

  No

• Is the seat belt used correctly?

  Yes

  No

• Is the seat attached with both LATCH and belt?

  Yes

  No

• Is the top tether strap used?

  Yes

  No

  No Tether

• Is it used correctly?

  Yes

  No

Current Seat Information

• Is the seat information missing?

  Yes

  No

• Seat manufacturer

  Select Angel Guard Baby Trend Britax Chicco Clek Combi Convaid Cosco Cybex Diono/Sunshine Kids Dream on Me Eddie Bauer Evenflo The First Years Graco Harmony Kiddy World KIDSEmbrace Orbit Maxi Cosi Merritt Peg/Perego Patterson Recaro Safety 1st SnugSeat Special Tomato Summer UPPAbaby

  • Angel Guard
  • Baby Trend
  • Britax
  • Chicco
  • Clek
  • Combi
  • Convaid
  • Cosco
  • Cybex
  • Diono/Sunshine Kids
  • Dream on Me
  • Eddie Bauer
  • Evenflo
  • The First Years
  • Graco
  • Harmony
  • Kiddy World
  • KIDSEmbrace
  • Orbit
  • Maxi Cosi
  • Merritt
  • Peg/Perego
  • Patterson
  • Recaro
  • Safety 1st
  • SnugSeat
  • Special Tomato
  • Summer
  • UPPAbaby

• Seat model name

• Seat model number

• Date of manufacture

  Date

• Is the seat expired?

  Yes

  No

• Is the participant the original owner of the seat?

  Yes

  No

• Has the seat been in a crash?

  Yes

  No

• Was the registration card sent in?

  Yes

  No

• With the participant's current address?

  Yes

  No

• NHTSA Recall List
  http://www-odi.nhtsa.dot.gov/recalls/childseat.cfm?MfgID=All

• Is there a recall on this seat?

  Yes

  No

• Has the recall been repaired?

  Yes

  No

• Is this a US certified (FMVSS 213) seat?

  Yes

  No

• Did the child get a new seat at the event?

  Yes

  No

• New seat manufacturer

• New seat model name

• New seat model number

• New seat date of manufacture

  Date

• Who provided the seat?

  Participant

  Clinic

• Who registered the seat?

  Participant

  Clinic

• Final Install with?

  LATCH

  Seat Belt

• Used the top tether?

  Yes

  No

• Draw the final location of the seat (X). Use a M if the seat was moved. D for the driver.

  Drawing

• Photograph if desired.

  Media

• Final comments on installation

• What type of seat is it?

  Infant-only

  Convertible/rear facing

  Convertible/forward facing

  Combo - ff only

  Car Bed

• Is the seat installed with a base?

  Yes

  No

• Does the seat have a five-point harness?

  Yes

  No

• Is the handle in the proper position?

  Yes

  No

• Is the seat reclined properly for the age of the child?

  Yes

  No

• Is the seat reclined properly for the age of the child?

  Yes

  No

• Is the seat properly upright?

  Yes

  No

• Is the child the correct age/weight/height for this seat?

  Yes

  No

• Is this seat facing the appropriate direction for this child?

  Yes

  No

• Is the seat attached with LATCH?

  Yes

  No

• Is the LATCH system holding the seat tightly (1" test)?

  Yes

  No

• Is the LATCH used correctly?

  Yes

  No

• Is the seat attached with the safety belt?

  Yes

  No

• Is the belt holding the seat tightly (1" test)?

  Yes

  No

• Is the belt routed through the seat correctly?

  Yes

  No

• What type of belt was used?

  Lap/shoulder belt

  Lap only belt

  Other

• What type of retractor was used?

  Switchable/locked mode

  Switchable/unlocked

  ELR

  ALR

  None

• What type of latchplate was used?

  Freesliding

  Locking

  Fixed/sewn

  Switchable/locked

  Switchable/unlocked

• Is a locking clip needed?

  Yes

  No

• Is it used?

  Yes

  No

• Is it used correctly?

  Yes

  No

• Are any safety belt after-market products used?

  Yes

  No

• Is the seat belt used correctly?

  Yes

  No

• Is the seat attached with both LATCH and belt?

  Yes

  No

• Is the top tether strap used?

  Yes

  No

  No Tether

• Is it used correctly?

  Yes

  No

Current Seat Information

• Is the seat information missing?

  Yes

  No

• Seat manufacturer

  Select Angel Guard Baby Trend Britax Chicco Clek Combi Convaid Cosco Cybex Diono/Sunshine Kids Dream on Me Eddie Bauer Evenflo The First Years Graco Harmony Kiddy World KIDSEmbrace Orbit Maxi Cosi Merritt Peg/Perego Patterson Recaro Safety 1st SnugSeat Special Tomato Summer UPPAbaby

  • Angel Guard
  • Baby Trend
  • Britax
  • Chicco
  • Clek
  • Combi
  • Convaid
  • Cosco
  • Cybex
  • Diono/Sunshine Kids
  • Dream on Me
  • Eddie Bauer
  • Evenflo
  • The First Years
  • Graco
  • Harmony
  • Kiddy World
  • KIDSEmbrace
  • Orbit
  • Maxi Cosi
  • Merritt
  • Peg/Perego
  • Patterson
  • Recaro
  • Safety 1st
  • SnugSeat
  • Special Tomato
  • Summer
  • UPPAbaby

• Seat model name

• Seat model number

• Date of manufacture

  Date

• Is the seat expired?

  Yes

  No

• Is the participant the original owner of the seat?

  Yes

  No

• Has the seat been in a crash?

  Yes

  No

• Was the registration card sent in?

  Yes

  No

• With the participant's current address?

  Yes

  No

• NHTSA Recall List
  http://www-odi.nhtsa.dot.gov/recalls/childseat.cfm?MfgID=All

• Is there a recall on this seat?

  Yes

  No

• Has the recall been repaired?

  Yes

  No

• Is this a US certified (FMVSS 213) seat?

  Yes

  No

• Did the child get a new seat at the event?

  Yes

  No

• New seat manufacturer

• New seat model name

• New seat model number

• New seat date of manufacture

  Date

• Who provided the seat?

  Participant

  Clinic

• Who registered the seat?

  Participant

  Clinic

• Final Install with?

  LATCH

  Seat Belt

• Used the top tether?

  Yes

  No

• Draw the final location of the seat (X). Use a M if the seat was moved. D for the driver.

  Drawing

• Photograph if desired.

  Media

• Final comments on installation

• What type of seat is it?

  Infant-only

  Convertible/rear facing

  Convertible/forward facing

  Combo - ff only

  Car Bed

• Does the seat have a base?

  Yes

  No

• Does the seat have a five-point harness?

  Yes

  No

• Are any safety belt after-market products used?

  Yes

  No

• Is the child the correct age/weight/height for this seat?

  Yes

  No

Current Seat Information

• Is the seat information missing?

  Yes

  No

• Seat manufacturer

  Select Angel Guard Baby Trend Britax Chicco Clek Combi Convaid Cosco Cybex Diono/Sunshine Kids Dream on Me Eddie Bauer Evenflo The First Years Graco Harmony Kiddy World KIDSEmbrace Orbit Maxi Cosi Merritt Peg/Perego Patterson Recaro Safety 1st SnugSeat Special Tomato Summer UPPAbaby

  • Angel Guard
  • Baby Trend
  • Britax
  • Chicco
  • Clek
  • Combi
  • Convaid
  • Cosco
  • Cybex
  • Diono/Sunshine Kids
  • Dream on Me
  • Eddie Bauer
  • Evenflo
  • The First Years
  • Graco
  • Harmony
  • Kiddy World
  • KIDSEmbrace
  • Orbit
  • Maxi Cosi
  • Merritt
  • Peg/Perego
  • Patterson
  • Recaro
  • Safety 1st
  • SnugSeat
  • Special Tomato
  • Summer
  • UPPAbaby

• Seat model name

• Seat model number

• Date of manufacture

  Date

• Is the seat expired?

  Yes

  No

• Is the participant the original owner of the seat?

  Yes

  No

• Has the seat been in a crash?

  Yes

  No

• Was the registration card sent in?

  Yes

  No

• With the participant's current address?

  Yes

  No

• NHTSA Recall List
  http://www-odi.nhtsa.dot.gov/recalls/childseat.cfm?MfgID=All

• Is there a recall on this seat?

  Yes

  No

• Has the recall been repaired?

  Yes

  No

• Is this a US certified (FMVSS 213) seat?

  Yes

  No

• Did the child get a new seat at the event?

  Yes

  No

• New seat manufacturer

  Select Angel Guard Baby Trend Britax Chicco Clek Combi Convaid Cosco Cybex Diono/Sunshine Kids Dream on Me Eddie Bauer Evenflo The First Years Graco Harmony Kiddy World KIDSEmbrace Orbit Maxi Cosi Merritt Peg/Perego Patterson Recaro Safety 1st SnugSeat Special Tomato Summer UPPAbaby

  • Angel Guard
  • Baby Trend
  • Britax
  • Chicco
  • Clek
  • Combi
  • Convaid
  • Cosco
  • Cybex
  • Diono/Sunshine Kids
  • Dream on Me
  • Eddie Bauer
  • Evenflo
  • The First Years
  • Graco
  • Harmony
  • Kiddy World
  • KIDSEmbrace
  • Orbit
  • Maxi Cosi
  • Merritt
  • Peg/Perego
  • Patterson
  • Recaro
  • Safety 1st
  • SnugSeat
  • Special Tomato
  • Summer
  • UPPAbaby

• New seat model name

• New seat model number

• New seat date of manufacture

  Date

• Who provided the seat?

  Participant

  Clinic

• Who registered the seat?

  Participant

  Clinic

• Final Install with?

  LATCH

  Seat Belt

• Used the top tether?

  Yes

  No

• Draw the final location of the seat (X). Use a M if the seat was moved. D for the driver.

  Drawing

• Photograph if desired.

  Media

• Final comments on installation

• Step 1: Is the child sitting all the way back against the auto seat?

  Yes

  No

• Step 2: Are the child’s knees bending comfortably at the edge of the auto seat?

  Yes

  No

• Step 3: Does the belt cross the shoulder between the neck and arm?

  Yes

  No

• Step 4: Is the lap belt as low as possible, touching the thighs?

  Yes

  No

• Step 5: Does the child stay seated like this for the whole trip?

  Yes

  No

• Did the child get a new seat at the event?

  Yes

  No

• New seat manufacturer

  Select Angel Guard Baby Trend Britax Chicco Clek Combi Convaid Cosco Cybex Diono/Sunshine Kids Dream on Me Eddie Bauer Evenflo The First Years Graco Harmony Kiddy World KIDSEmbrace Orbit Maxi Cosi Merritt Peg/Perego Patterson Recaro Safety 1st SnugSeat Special Tomato Summer UPPAbaby

  • Angel Guard
  • Baby Trend
  • Britax
  • Chicco
  • Clek
  • Combi
  • Convaid
  • Cosco
  • Cybex
  • Diono/Sunshine Kids
  • Dream on Me
  • Eddie Bauer
  • Evenflo
  • The First Years
  • Graco
  • Harmony
  • Kiddy World
  • KIDSEmbrace
  • Orbit
  • Maxi Cosi
  • Merritt
  • Peg/Perego
  • Patterson
  • Recaro
  • Safety 1st
  • SnugSeat
  • Special Tomato
  • Summer
  • UPPAbaby

• New seat model name

• New seat model number

• New seat date of manufacture

  Date

• Who provided the seat?

  Participant

  Clinic

• Who registered the seat?

  Participant

  Clinic

• Final Install with?

  LATCH

  Seat Belt

• Used the top tether?

  Yes

  No

• Draw the final location of the seat (X). Use a M if the seat was moved. D for the driver.

  Drawing

• Photograph if desired.

  Media

• Final comments on installation

• Is the child the correct age/weight/height for this seat?

  Yes

  No

• Is the harness snug?

  Yes

  No

• Is the harness in the correct slots?

  Yes

  No

• Has the harness retainer clip been used properly?

  Yes

  No

• Did the child get a new seat at the event?

  Yes

  No

• New seat manufacturer

  Select Angel Guard Baby Trend Britax Chicco Clek Combi Convaid Cosco Cybex Diono/Sunshine Kids Dream on Me Eddie Bauer Evenflo The First Years Graco Harmony Kiddy World KIDSEmbrace Orbit Maxi Cosi Merritt Peg/Perego Patterson Recaro Safety 1st SnugSeat Special Tomato Summer UPPAbaby

  • Angel Guard
  • Baby Trend
  • Britax
  • Chicco
  • Clek
  • Combi
  • Convaid
  • Cosco
  • Cybex
  • Diono/Sunshine Kids
  • Dream on Me
  • Eddie Bauer
  • Evenflo
  • The First Years
  • Graco
  • Harmony
  • Kiddy World
  • KIDSEmbrace
  • Orbit
  • Maxi Cosi
  • Merritt
  • Peg/Perego
  • Patterson
  • Recaro
  • Safety 1st
  • SnugSeat
  • Special Tomato
  • Summer
  • UPPAbaby

• New seat model name

• New seat model number

• New seat date of manufacture

  Date

• Who provided the seat?

  Participant

  Clinic

• Who registered the seat?

  Participant

  Clinic

• Final Install with?

  LATCH

  Seat Belt

• Used the top tether?

  Yes

  No

• Draw the final location of the seat (X). Use a M if the seat was moved. D for the driver.

  Drawing

• Photograph if desired.

  Media

• Final comments on installation

• Is the child the correct age/weight/height for this vest?

  Yes

  No

• Is the vest attached with LATCH?

  Yes

  No

• Is the LATCH system holding the vest tightly?

  Yes

  No

• Is the LATCH used correctly?

  Yes

  No

• Is the vest attached with the safety belt?

  Yes

  No

• Is the belt holding the vest tightly?

  Yes

  No

• Is the belt routed through the vest correctly?

  Yes

  No

• What type of belt was used?

  Lap/shoulder belt

  Lap only belt

  Other

• What type of retractor was used?

  Switchable/locked mode

  Switchable/unlocked

  ELR

  ALR

  None

• What type of latchplate was used?

  Freesliding

  Locking

  Fixed/sewn

  Switchable/locked

  Switchable/unlocked

• Is a locking clip needed?

  Yes

  No

• Is it used?

  Yes

  No

• Is it used correctly?

  Yes

  No

• Are any safety belt after-market products used?

  Yes

  No

• Is the seat belt used correctly?

  Yes

  No

• Is the vest attached with both LATCH and belt?

  Yes

  No

• Is the top tether strap used?

  Yes

  No

  No Tether

• Is it used correctly?

  Yes

  No

Current Seat Information

• Is the vest information missing?

  Yes

  No

• Vest manufacturer

  E-Z-On

  Safe Traffic Systems

• Vest model name

• Vest model number

• Date of manufacture

  Date

• Is the vest expired?

  Yes

  No

• Is the participant the original owner of the vest?

  Yes

  No

• Has the vest been in a crash?

  Yes

  No

• Was the registration card sent in?

  Yes

  No

• With the participant's current address?

  Yes

  No

• NHTSA Recall List
  http://www-odi.nhtsa.dot.gov/recalls/childseat.cfm?MfgID=All

• Is there a recall on this vest?

  Yes

  No

• Has the recall been repaired?

  Yes

  No

• Is this a US certified (FMVSS 213) vest?

  Yes

  No

• Did the child get a new seat at the event?

  Yes

  No

• New seat manufacturer

• New seat model name

• New seat model number

• New seat date of manufacture

  Date

• Who provided the seat?

  Participant

  Clinic

• Who registered the seat?

  Participant

  Clinic

• Final Install with?

  LATCH

  Seat Belt

• Used the top tether?

  Yes

  No

• Draw the final location of the seat (X). Use a M if the seat was moved. D for the driver.

  Drawing

• Photograph if desired.

  Media

• Final comments on installation

• Child 1 Name

• CRS Type

  Select Harnessed Seat Base-Only Booster Safety Belt Integrated Vest

  • Harnessed Seat
  • Base-Only
  • Booster
  • Safety Belt
  • Integrated
  • Vest

• Is the child the correct age/weight/height for this seat?

  Yes

  No

• Is the child present?

  Yes

  No

• Is the child sitting up, not slouching?

  Yes

  No

• Is the lap belt snug and low on the hips?

  Yes

  No

• Is the shoulder belt properly positioned?

  Yes

  No

• Is the buckle latched securely?

  Yes

  No

• Is it a high back or backless booster?

  High Back Booster

  Backless booster

• Is the seat attached with LATCH?

  Yes

  No

• Is LATCH use acceptable for this booster?

  Yes

  No

• Is the top tether strap used?

  Yes

  No

  No Tether

• Is it used correctly?

  Yes

  No

Current Booster Information

• Is booster information missing?

  Yes

  No

• Booster manufacturer

  Select Britax BubbleBum Chicco Clek Combi Cosco Cybex Diono Evenflo The First Years GOBOOSTER Graco Harmony Kiddy Maxi-Cosi Peg Perego Recaro Safety 1st

  • Britax
  • BubbleBum
  • Chicco
  • Clek
  • Combi
  • Cosco
  • Cybex
  • Diono
  • Evenflo
  • The First Years
  • GOBOOSTER
  • Graco
  • Harmony
  • Kiddy
  • Maxi-Cosi
  • Peg Perego
  • Recaro
  • Safety 1st

• Booster model name

• Booster model number

• Date of manufacture

  Date

• Is the booster expired?

  Yes

  No

• Is the participant the original owner of the booster?

  Yes

  No

• Has the booster been in a crash?

  Yes

  No

• Was the registration card sent in?

  Yes

  No

• With the participant's current address?

  Yes

  No

• NHTSA Recall List
  http://www-odi.nhtsa.dot.gov/recalls/childseat.cfm?MfgID=All

• Is there a recall on this booster?

  Yes

  No

• Has the recall been repaired?

  Yes

  No

• Is this a US certified (FMVSS 213) booster?

  Yes

  No

• Did the child get a new seat at the event?

  Yes

  No

• New seat manufacturer

  Yes

  No

  N/A

• New seat model name

• New seat model number

• New seat date of manufacture

  Date

• Who provided the seat?

  Participant

  Clinic

• Who registered the seat?

  Participant

  Clinic

• Final Install with?

  LATCH

  Seat Belt

• Used the top tether?

  Yes

  No

• Draw the final location of the seat (X). Use a M if the seat was moved. D for the driver.

  Drawing

• Photograph if desired.

  Media

• Final comments on installation

• Is the child the correct age/weight/height for this seat?

  Yes

  No

• Is the base installed on arrival?

  Yes

  No

• Is the base attached with LATCH?

  Yes

  No

• Is the LATCH system holding the base tightly (1" test)?

  Yes

  No

• Is the LATCH used correctly?

  Yes

  No

• Is the base attached with the safety belt?

  Yes

  No

• Is the belt holding the base tightly (1" test)?

  Yes

  No

• Is the belt routed through the base correctly?

  Yes

  No

• What type of belt was used?

  Lap/shoulder belt

  Lap only belt

  Other

• What type of retractor was used?

  Switchable/locked mode

  Switchable/unlocked

  ELR

  ALR

  None

• What type of latchplate was used?

  Freesliding

  Locking

  Fixed/sewn

  Switchable/locked

  Switchable/unlocked

• Is a locking clip needed?

  Yes

  No

• Is it used?

  Yes

  No

• Is it used correctly?

  Yes

  No

• Is the seat belt used correctly?

  Yes

  No

• Is the base attached with both LATCH and belt?

  Yes

  No

Current Seat Information

• Is the seat information missing?

  Yes

  No

• Base manufacturer

  Select Baby Trend Britax Chicco Combi Cosco Cybex Dream on Me Eddie Bauer Evenflo The First Years Graco Maxi-Cosi Orbit Peg/Perego Recaro Safety 1st Summer UPPAbaby

  • Baby Trend
  • Britax
  • Chicco
  • Combi
  • Cosco
  • Cybex
  • Dream on Me
  • Eddie Bauer
  • Evenflo
  • The First Years
  • Graco
  • Maxi-Cosi
  • Orbit
  • Peg/Perego
  • Recaro
  • Safety 1st
  • Summer
  • UPPAbaby

• Base model name

• Base model number

• Date of manufacture

  Date

• Is the base expired?

  Yes

  No

• Is the participant the original owner of the base?

  Yes

  No

• Has the base been in a crash?

  Yes

  No

• Was the registration card sent in?

  Yes

  No

• With the participant's current address?

  Yes

  No

• NHTSA Recall List
  http://www-odi.nhtsa.dot.gov/recalls/childseat.cfm?MfgID=All

• Is there a recall on this base?

  Yes

  No

• Has the recall been repaired?

  Yes

  No

• Is this a US certified (FMVSS 213) base?

  Yes

  No

• Did the child get a new seat at the event?

  Yes

  No

• New seat manufacturer

• New seat model name

• New seat model number

• New seat date of manufacture

  Date

• Who provided the seat?

  Participant

  Clinic

• Who registered the seat?

  Participant

  Clinic

• Final Install with?

  LATCH

  Seat Belt

• Used the top tether?

  Yes

  No

• Draw the final location of the seat (X). Use a M if the seat was moved. D for the driver.

  Drawing

• Photograph if desired.

  Media

• Final comments on installation

• Is the seat installed on arrival?

  Yes

  No

• Is the child present?

  Yes

  No

• What type of seat is it?

  Infant-only

  Convertible/rear facing

  Convertible/forward facing

  Combo - ff only

  Car Bed

• Is the seat installed with a base?

  Yes

  No

• Does the seat have a five-point harness?

  Yes

  No

• Is the handle in the proper position?

  Yes

  No

• Is the seat reclined properly for the age of the child?

  Yes

  No

• Is the seat reclined properly for the age of the child?

  Yes

  No

• Is the seat properly upright?

  Yes

  No

• Is the child the correct age/weight/height for this seat?

  Yes

  No

• Is this seat facing the appropriate direction for this child?

  Yes

  No

• Is the harness snug?

  Yes

  No

• Is the harness in the correct slots?

  Yes

  No

• Has the harness retainer clip been used properly?

  Yes

  No

• Is the seat attached with LATCH?

  Yes

  No

• Is the LATCH system holding the seat tightly (1" test)?

  Yes

  No

• Is the LATCH used correctly?

  Yes

  No

• Is the seat attached with the safety belt?

  Yes

  No

• Is the belt holding the seat tightly (1" test)?

  Yes

  No

• Is the belt routed through the seat correctly?

  Yes

  No

• What type of belt was used?

  Lap/shoulder belt

  Lap only belt

  Other

• What type of retractor was used?

  Switchable/locked mode

  Switchable/unlocked

  ELR

  ALR

  None

• What type of latchplate was used?

  Freesliding

  Locking

  Fixed/sewn

  Switchable/locked

  Switchable/unlocked

• Is a locking clip needed?

  Yes

  No

• Is it used?

  Yes

  No

• Is it used correctly?

  Yes

  No

• Are any safety belt after-market products used?

  Yes

  No

• Is the seat belt used correctly?

  Yes

  No

• Is the seat attached with both LATCH and belt?

  Yes

  No

• Is the top tether strap used?

  Yes

  No

  No Tether

• Is it used correctly?

  Yes

  No

Current Seat Information

• Is the seat information missing?

  Yes

  No

• Seat manufacturer

  Select Angel Guard Baby Trend Britax Chicco Clek Combi Convaid Cosco Cybex Diono/Sunshine Kids Dream on Me Eddie Bauer Evenflo The First Years Graco Harmony Kiddy World KIDSEmbrace Orbit Maxi Cosi Merritt Peg/Perego Patterson Recaro Safety 1st SnugSeat Special Tomato Summer UPPAbaby

  • Angel Guard
  • Baby Trend
  • Britax
  • Chicco
  • Clek
  • Combi
  • Convaid
  • Cosco
  • Cybex
  • Diono/Sunshine Kids
  • Dream on Me
  • Eddie Bauer
  • Evenflo
  • The First Years
  • Graco
  • Harmony
  • Kiddy World
  • KIDSEmbrace
  • Orbit
  • Maxi Cosi
  • Merritt
  • Peg/Perego
  • Patterson
  • Recaro
  • Safety 1st
  • SnugSeat
  • Special Tomato
  • Summer
  • UPPAbaby

• Seat model name

• Seat model number

• Date of manufacture

  Date

• Is the seat expired?

  Yes

  No

• Is the participant the original owner of the seat?

  Yes

  No

• Has the seat been in a crash?

  Yes

  No

• Was the registration card sent in?

  Yes

  No

• With the participant's current address?

  Yes

  No

• NHTSA Recall List
  http://www-odi.nhtsa.dot.gov/recalls/childseat.cfm?MfgID=All

• Is there a recall on this seat?

  Yes

  No

• Has the recall been repaired?

  Yes

  No

• Is this a US certified (FMVSS 213) seat?

  Yes

  No

• Did the child get a new seat at the event?

  Yes

  No

• New seat manufacturer

• New seat model name

• New seat model number

• New seat date of manufacture

  Date

• Who provided the seat?

  Participant

  Clinic

• Who registered the seat?

  Participant

  Clinic

• Final Install with?

  LATCH

  Seat Belt

• Used the top tether?

  Yes

  No

• Draw the final location of the seat (X). Use a M if the seat was moved. D for the driver.

  Drawing

• Photograph if desired.

  Media

• Final comments on installation

• What type of seat is it?

  Infant-only

  Convertible/rear facing

  Convertible/forward facing

  Combo - ff only

  Car Bed

• Is the seat installed with a base?

  Yes

  No

• Does the seat have a five-point harness?

  Yes

  No

• Is the handle in the proper position?

  Yes

  No

• Is the seat reclined properly for the age of the child?

  Yes

  No

• Is the seat reclined properly for the age of the child?

  Yes

  No

• Is the seat properly upright?

  Yes

  No

• Is the child the correct age/weight/height for this seat?

  Yes

  No

• Is this seat facing the appropriate direction for this child?

  Yes

  No

• Is the seat attached with LATCH?

  Yes

  No

• Is the LATCH system holding the seat tightly (1" test)?

  Yes

  No

• Is the LATCH used correctly?

  Yes

  No

• Is the seat attached with the safety belt?

  Yes

  No

• Is the belt holding the seat tightly (1" test)?

  Yes

  No

• Is the belt routed through the seat correctly?

  Yes

  No

• What type of belt was used?

  Lap/shoulder belt

  Lap only belt

  Other

• What type of retractor was used?

  Switchable/locked mode

  Switchable/unlocked

  ELR

  ALR

  None

• What type of latchplate was used?

  Freesliding

  Locking

  Fixed/sewn

  Switchable/locked

  Switchable/unlocked

• Is a locking clip needed?

  Yes

  No

• Is it used?

  Yes

  No

• Is it used correctly?

  Yes

  No

• Are any safety belt after-market products used?

  Yes

  No

• Is the seat belt used correctly?

  Yes

  No

• Is the seat attached with both LATCH and belt?

  Yes

  No

• Is the top tether strap used?

  Yes

  No

  No Tether

• Is it used correctly?

  Yes

  No

Current Seat Information

• Is the seat information missing?

  Yes

  No

• Seat manufacturer

  Select Angel Guard Baby Trend Britax Chicco Clek Combi Convaid Cosco Cybex Diono/Sunshine Kids Dream on Me Eddie Bauer Evenflo The First Years Graco Harmony Kiddy World KIDSEmbrace Orbit Maxi Cosi Merritt Peg/Perego Patterson Recaro Safety 1st SnugSeat Special Tomato Summer UPPAbaby

  • Angel Guard
  • Baby Trend
  • Britax
  • Chicco
  • Clek
  • Combi
  • Convaid
  • Cosco
  • Cybex
  • Diono/Sunshine Kids
  • Dream on Me
  • Eddie Bauer
  • Evenflo
  • The First Years
  • Graco
  • Harmony
  • Kiddy World
  • KIDSEmbrace
  • Orbit
  • Maxi Cosi
  • Merritt
  • Peg/Perego
  • Patterson
  • Recaro
  • Safety 1st
  • SnugSeat
  • Special Tomato
  • Summer
  • UPPAbaby

• Seat model name

• Seat model number

• Date of manufacture

  Date

• Is the seat expired?

  Yes

  No

• Is the participant the original owner of the seat?

  Yes

  No

• Has the seat been in a crash?

  Yes

  No

• Was the registration card sent in?

  Yes

  No

• With the participant's current address?

  Yes

  No

• NHTSA Recall List
  http://www-odi.nhtsa.dot.gov/recalls/childseat.cfm?MfgID=All

• Is there a recall on this seat?

  Yes

  No

• Has the recall been repaired?

  Yes

  No

• Is this a US certified (FMVSS 213) seat?

  Yes

  No

• Did the child get a new seat at the event?

  Yes

  No

• New seat manufacturer

• New seat model name

• New seat model number

• New seat date of manufacture

  Date

• Who provided the seat?

  Participant

  Clinic

• Who registered the seat?

  Participant

  Clinic

• Final Install with?

  LATCH

  Seat Belt

• Used the top tether?

  Yes

  No

• Draw the final location of the seat (X). Use a M if the seat was moved. D for the driver.

  Drawing

• Photograph if desired.

  Media

• Final comments on installation

• What type of seat is it?

  Infant-only

  Convertible/rear facing

  Convertible/forward facing

  Combo - ff only

  Car Bed

• Does the seat have a base?

  Yes

  No

• Does the seat have a five-point harness?

  Yes

  No

• Are any safety belt after-market products used?

  Yes

  No

• Is the child the correct age/weight/height for this seat?

  Yes

  No

Current Seat Information

• Is the seat information missing?

  Yes

  No

• Seat manufacturer

  Select Angel Guard Baby Trend Britax Chicco Clek Combi Convaid Cosco Cybex Diono/Sunshine Kids Dream on Me Eddie Bauer Evenflo The First Years Graco Harmony Kiddy World KIDSEmbrace Orbit Maxi Cosi Merritt Peg/Perego Patterson Recaro Safety 1st SnugSeat Special Tomato Summer UPPAbaby

  • Angel Guard
  • Baby Trend
  • Britax
  • Chicco
  • Clek
  • Combi
  • Convaid
  • Cosco
  • Cybex
  • Diono/Sunshine Kids
  • Dream on Me
  • Eddie Bauer
  • Evenflo
  • The First Years
  • Graco
  • Harmony
  • Kiddy World
  • KIDSEmbrace
  • Orbit
  • Maxi Cosi
  • Merritt
  • Peg/Perego
  • Patterson
  • Recaro
  • Safety 1st
  • SnugSeat
  • Special Tomato
  • Summer
  • UPPAbaby

• Seat model name

• Seat model number

• Date of manufacture

  Date

• Is the seat expired?

  Yes

  No

• Is the participant the original owner of the seat?

  Yes

  No

• Has the seat been in a crash?

  Yes

  No

• Was the registration card sent in?

  Yes

  No

• With the participant's current address?

  Yes

  No

• NHTSA Recall List
  http://www-odi.nhtsa.dot.gov/recalls/childseat.cfm?MfgID=All

• Is there a recall on this seat?

  Yes

  No

• Has the recall been repaired?

  Yes

  No

• Is this a US certified (FMVSS 213) seat?

  Yes

  No

• Did the child get a new seat at the event?

  Yes

  No

• New seat manufacturer

  Select Angel Guard Baby Trend Britax Chicco Clek Combi Convaid Cosco Cybex Diono/Sunshine Kids Dream on Me Eddie Bauer Evenflo The First Years Graco Harmony Kiddy World KIDSEmbrace Orbit Maxi Cosi Merritt Peg/Perego Patterson Recaro Safety 1st SnugSeat Special Tomato Summer UPPAbaby

  • Angel Guard
  • Baby Trend
  • Britax
  • Chicco
  • Clek
  • Combi
  • Convaid
  • Cosco
  • Cybex
  • Diono/Sunshine Kids
  • Dream on Me
  • Eddie Bauer
  • Evenflo
  • The First Years
  • Graco
  • Harmony
  • Kiddy World
  • KIDSEmbrace
  • Orbit
  • Maxi Cosi
  • Merritt
  • Peg/Perego
  • Patterson
  • Recaro
  • Safety 1st
  • SnugSeat
  • Special Tomato
  • Summer
  • UPPAbaby

• New seat model name

• New seat model number

• New seat date of manufacture

  Date

• Who provided the seat?

  Participant

  Clinic

• Who registered the seat?

  Participant

  Clinic

• Final Install with?

  LATCH

  Seat Belt

• Used the top tether?

  Yes

  No

• Draw the final location of the seat (X). Use a M if the seat was moved. D for the driver.

  Drawing

• Photograph if desired.

  Media

• Final comments on installation

• Step 1: Is the child sitting all the way back against the auto seat?

  Yes

  No

• Step 2: Are the child’s knees bending comfortably at the edge of the auto seat?

  Yes

  No

• Step 3: Does the belt cross the shoulder between the neck and arm?

  Yes

  No

• Step 4: Is the lap belt as low as possible, touching the thighs?

  Yes

  No

• Step 5: Does the child stay seated like this for the whole trip?

  Yes

  No

• Did the child get a new seat at the event?

  Yes

  No

• New seat manufacturer

  Select Angel Guard Baby Trend Britax Chicco Clek Combi Convaid Cosco Cybex Diono/Sunshine Kids Dream on Me Eddie Bauer Evenflo The First Years Graco Harmony Kiddy World KIDSEmbrace Orbit Maxi Cosi Merritt Peg/Perego Patterson Recaro Safety 1st SnugSeat Special Tomato Summer UPPAbaby

  • Angel Guard
  • Baby Trend
  • Britax
  • Chicco
  • Clek
  • Combi
  • Convaid
  • Cosco
  • Cybex
  • Diono/Sunshine Kids
  • Dream on Me
  • Eddie Bauer
  • Evenflo
  • The First Years
  • Graco
  • Harmony
  • Kiddy World
  • KIDSEmbrace
  • Orbit
  • Maxi Cosi
  • Merritt
  • Peg/Perego
  • Patterson
  • Recaro
  • Safety 1st
  • SnugSeat
  • Special Tomato
  • Summer
  • UPPAbaby

• New seat model name

• New seat model number

• New seat date of manufacture

  Date

• Who provided the seat?

  Participant

  Clinic

• Who registered the seat?

  Participant

  Clinic

• Final Install with?

  LATCH

  Seat Belt

• Used the top tether?

  Yes

  No

• Draw the final location of the seat (X). Use a M if the seat was moved. D for the driver.

  Drawing

• Photograph if desired.

  Media

• Final comments on installation

• Is the child the correct age/weight/height for this seat?

  Yes

  No

• Is the harness snug?

  Yes

  No

• Is the harness in the correct slots?

  Yes

  No

• Has the harness retainer clip been used properly?

  Yes

  No

• Did the child get a new seat at the event?

  Yes

  No

• New seat manufacturer

  Select Angel Guard Baby Trend Britax Chicco Clek Combi Convaid Cosco Cybex Diono/Sunshine Kids Dream on Me Eddie Bauer Evenflo The First Years Graco Harmony Kiddy World KIDSEmbrace Orbit Maxi Cosi Merritt Peg/Perego Patterson Recaro Safety 1st SnugSeat Special Tomato Summer UPPAbaby

  • Angel Guard
  • Baby Trend
  • Britax
  • Chicco
  • Clek
  • Combi
  • Convaid
  • Cosco
  • Cybex
  • Diono/Sunshine Kids
  • Dream on Me
  • Eddie Bauer
  • Evenflo
  • The First Years
  • Graco
  • Harmony
  • Kiddy World
  • KIDSEmbrace
  • Orbit
  • Maxi Cosi
  • Merritt
  • Peg/Perego
  • Patterson
  • Recaro
  • Safety 1st
  • SnugSeat
  • Special Tomato
  • Summer
  • UPPAbaby

• New seat model name

• New seat model number

• New seat date of manufacture

  Date

• Who provided the seat?

  Participant

  Clinic

• Who registered the seat?

  Participant

  Clinic

• Final Install with?

  LATCH

  Seat Belt

• Used the top tether?

  Yes

  No

• Draw the final location of the seat (X). Use a M if the seat was moved. D for the driver.

  Drawing

• Photograph if desired.

  Media

• Final comments on installation

• Is the child the correct age/weight/height for this vest?

  Yes

  No

• Is the vest attached with LATCH?

  Yes

  No

• Is the LATCH system holding the vest tightly?

  Yes

  No

• Is the LATCH used correctly?

  Yes

  No

• Is the vest attached with the safety belt?

  Yes

  No

• Is the belt holding the vest tightly?

  Yes

  No

• Is the belt routed through the vest correctly?

  Yes

  No

• What type of belt was used?

  Lap/shoulder belt

  Lap only belt

  Other

• What type of retractor was used?

  Switchable/locked mode

  Switchable/unlocked

  ELR

  ALR

  None

• What type of latchplate was used?

  Freesliding

  Locking

  Fixed/sewn

  Switchable/locked

  Switchable/unlocked

• Is a locking clip needed?

  Yes

  No

• Is it used?

  Yes

  No

• Is it used correctly?

  Yes

  No

• Are any safety belt after-market products used?

  Yes

  No

• Is the seat belt used correctly?

  Yes

  No

• Is the vest attached with both LATCH and belt?

  Yes

  No

• Is the top tether strap used?

  Yes

  No

  No Tether

• Is it used correctly?

  Yes

  No