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Child Passenger Safety Inspection Form
Child Passenger Safety Inspection Form
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Child Passenger Safety Inspection Form

Safe Kids Wyoming

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Free Child Passenger Safety Inspection Form Checklist

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Title Page

Participant Information:

  • Time/date

  • Driver's name

  • Driver's address

  • Phone number

  • E-mail

  • Relationship to Child

Waiver of Liability

  • I understand that the sole purpose of this program is to reduce the incidence of improper installation and use of child safety seats; that this inspection is provided free of charge in the interest of public safety; that this program cannot fully evaluate the quality, safety or condition of the child safety seat, any component of my vehicle including the seats, safety belts and airbag systems; this program cannot guarantee my child's safety in a crash. I understand that to have full protective benefit of the child safety seat the infant and/or child must at all times be properly secured to the child safety seat and the child safety seat must at all times by properly secured to the vehicle in accordance with the vehicle and child safety seat manufacturer's instructions. I hereby release any program participants from any present or future liability for any injuries including death or dangers that may result from a vehicle collision or otherwise.<br><br>I understand that on occasion a great deal of force must be used to properly secure the child safety seat into the vehicle. I release all agencies and personnel involved from liability and responsibility for any and all damage(s) caused to my vehicle and/or contents therein while installing the child safety seats.

  • Participant Signature

Vehicle Information

  • Vehicle year

  • Vehicle make and model

  • How many children in seatbelts?

  • How many child safety seats in the vehicle?

  • How many adults in seatbelts?

  • Do the Adults Wear Seatbelts?

  • Have any of the car seats been involved in a crash?

  • Airbags

    • Front Driver
    • Front Passenger
    • Side
    • Curtain
    • None
    • On/Off Switch Engaged

Inspection Seat/Child (COMPLETE AS SEAT WAS FOUND)

  • Child 1

  • Child seat checked before?

  • Child Present?

  • Child's First Name

  • Child's Age

  • Child's Weight (lbs)

  • Child's Height (Inches)

  • Child's Date of Birth.

On Arrival.

  • 1.) Location of Occupants (D = Driver; X = CSS Found; M = CSS Moved)

  • 2.) CSS Installed Using (Select All That Apply)

  • No CSS (Mark- Go to #18

  • Uninstalled

  • Seatbelt

  • Tether

  • Lower Anchors

  • Integrated Seat (Mark - Go To #7)

  • 3.) CRS Type

    • Rear Facing Only w/o Base
    • Rear Facing Only with Base
    • Base Only
    • Rear Facing Convertible
    • Forward Facing with Harness
    • Belt Positioning Booster
    • Lap/Shoulder (Go to #17)
    • Lap Only (Go to #17)
    • Car Bed
    • Vest

  • Picture of Seat as it was found

  • 4.) Manufacturer:

  • Model Name:

  • 5.) Model Number:

  • 6.) Manufacture Date: mm/dd/yyyy

FINDINGS

  • 7.) CSS History Known?

  • 8.) CSS Involved in a Crash

  • 9.) CSS Labels Missing

  • 10.) CSS Recalled?

  • RECALL List checked?

  • NHTSA Recall List: http://www-odi.nhtsa.dot.gov/cars/problems/recalls/childseat.cfm
    http://www-odi.nhtsa.dot.gov/cars/problems/recalls/childseat.cfm

  • 11.) CSS on Recall List?

  • Participant Notified?

  • Problem corrected?

  • 12.) Is seat facing correct direction?

  • 13.) Is harness in correct harness slots?

  • If harnessed CSS, is it tightly installed? (1" test)

  • Are harness straps snug?

  • Is harness retainer clip at armpit level?

  • Is harness free of tears or twists?

  • 14.) Is seat installed at the correct angle?

  • 15.) Is LATCH correctly used?

  • 16.) Is tether correctly used?

  • 17.) Seatbelt Correct?

  • Is safety belt in locked mode? (Locking clip, switched retractor or locking latch plate).

  • Is locking clip used correctly?

  • Is safety belt routed correctly? (Belt Path)

  • Is Child within Manufacturer's Recommended height and weight range(s)?

  • Is child seated in appropriate location in vehicle?

  • If present, is carrier handle in correct position for travel?

ON DEPARTURE

  • 18.) Child/ CSS Location in Vehicle? (D = Driver, X = CSS)

  • 19.) CSS Installed Using (select all that apply)

    • No CSS
    • Uninstalled
    • Seatbelt
    • Tether
    • Lower Anchors
    • Integrated Seat (Mark - Go to 25)

  • 20.) Coalition Provided a New CSS

  • 21.) Restraint Type?

    • Rear Facing Only w/o Base
    • Rear Facing Only with Base
    • Base Only
    • Rear Facing Convertible
    • Forward Facing with Harness
    • Belt Positioning Booster
    • Lap/Shoulder (Go to #17)
    • Lap Only (Go to #17)
    • Car Bed
    • Vest

  • 22.) CSS Manufacturer

  • Manufacture Date

  • 23.) Model Number

  • 25.) All Corrections Made?

  • 26.) CSS/Vehicle Compatible

  • 27.) Education Materials Given

  • Picture of Seat #1 upon completion of inspection

  • Child 2

  • Child Present?

  • Child seat checked before?

  • Child's First Name

  • Child's Age

  • Child's Weight (lbs)

  • Child's Height (Inches)

  • Child's Date of Birth.

On Arrival.

  • 2.) CSS Installed Using (Select All That Apply)

  • 1.) Location of Occupants (D = Driver; X = CSS Found; M = CSS Moved)

  • No CSS (Mark- Go to #18

  • Uninstalled

  • Seatbelt

  • Tether

  • Lower Anchors

  • Integrated Seat (Mark - Go To #7)

  • 3.) CRS Type

    • Rear Facing Only w/o Base
    • Rear Facing Only with Base
    • Base Only
    • Rear Facing Convertible
    • Forward Facing with Harness
    • Belt Positioning Booster
    • Lap/Shoulder (Go to #17)
    • Lap Only (Go to #17)
    • Car Bed
    • Vest

  • Picture of Seat as it was found

  • 4.) Manufacturer:

  • Model Name:

  • 5.) Model Number:

  • 6.) Manufacture Date: mm/dd/yyyy

FINDINGS

  • 7.) CSS History Known?

  • 8.) CSS Involved in a Crash

  • 9.) CSS Labels Missing

  • 10.) CSS Expired?

  • RECALL List checked?

  • NHTSA Recall List: http://www-odi.nhtsa.dot.gov/cars/problems/recalls/childseat.cfm
    http://www-odi.nhtsa.dot.gov/cars/problems/recalls/childseat.cfm

  • 11.) CSS on Recall List?

  • Participant Notified?

  • Problem corrected?

  • 12.) Is seat facing correct direction?

  • 13.) Is harness in correct harness slots?

  • If harnessed CSS, is it tightly installed? (1" test)

  • Are harness straps snug?

  • Is harness retainer clip at armpit level?

  • Is harness free of tears or twists?

  • 14.) Is seat installed at the correct angle?

  • 15.) Is LATCH correctly used?

  • 16.) Is tether correctly used?

  • 17.) Seatbelt Correct?

  • Is safety belt in locked mode? (Locking clip, switched retractor or locking latch plate).

  • Is locking clip used correctly?

  • Is safety belt routed correctly? (Belt Path)

  • Is Child within Manufacturer's Recommended height and weight range(s)?

  • Is child seated in appropriate location in vehicle?

  • If present, is carrier handle in correct position for travel?

ON DEPARTURE

  • 18.) Child/ CSS Location in Vehicle? (D = Driver, X = CSS)

  • 19.) CSS Installed Using (select all that apply)

    • No CSS
    • Uninstalled
    • Seatbelt
    • Tether
    • Lower Anchors
    • Integrated Seat (Mark - Go to 25)

  • 20.) Coalition Provided a New CSS

  • 21.) Restraint Type?

    • Rear Facing Only w/o Base
    • Rear Facing Only with Base
    • Base Only
    • Rear Facing Convertible
    • Forward Facing with Harness
    • Belt Positioning Booster
    • Lap/Shoulder (Go to #17)
    • Lap Only (Go to #17)
    • Car Bed
    • Vest

  • 22.) CSS Manufacturer

  • 23.) Model Number

  • Manufacture Date

  • 25.) All Corrections Made?

  • 26.) CSS/Vehicle Compatible

  • 27.) Education Materials Given

  • Picture of Seat #1 upon completion of inspection

  • Child 3

  • Child Present?

  • Child seat checked before?

  • Child's First Name

  • Child's Age

  • Child's Weight (lbs)

  • Child's Height (Inches)

  • Child's Date of Birth.

On Arrival.

  • 2.) CSS Installed Using (Select All That Apply)

  • 1.) Location of Occupants (D = Driver; X = CSS Found; M = CSS Moved)

  • No CSS (Mark- Go to #18

  • Uninstalled

  • Seatbelt

  • Tether

  • Lower Anchors

  • Integrated Seat (Mark - Go To #7)

  • 3.) CRS Type

    • Rear Facing Only w/o Base
    • Rear Facing Only with Base
    • Base Only
    • Rear Facing Convertible
    • Forward Facing with Harness
    • Belt Positioning Booster
    • Lap/Shoulder (Go to #17)
    • Lap Only (Go to #17)
    • Car Bed
    • Vest

  • Picture of Seat as it was found

  • 4.) Manufacturer:

  • Model Name:

  • 5.) Model Number:

  • 6.) Manufacture Date: mm/dd/yyyy

FINDINGS

  • 7.) CSS History Known?

  • 8.) CSS Involved in a Crash

  • 9.) CSS Labels Missing

  • 10.) CSS Expired?

  • RECALL List checked?

  • NHTSA Recall List: http://www-odi.nhtsa.dot.gov/cars/problems/recalls/childseat.cfm
    http://www-odi.nhtsa.dot.gov/cars/problems/recalls/childseat.cfm

  • 11.) CSS on Recall List?

  • Participant Notified?

  • Problem corrected?

  • 12.) Is seat facing correct direction?

  • 13.) Is harness in correct harness slots?

  • If harnessed CSS, is it tightly installed? (1" test)

  • Are harness straps snug?

  • Is harness retainer clip at armpit level?

  • Is harness free of tears or twists?

  • 14.) Is seat installed at the correct angle?

  • 15.) Is LATCH correctly used?

  • 16.) Is tether correctly used?

  • 17.) Seatbelt Correct?

  • Is safety belt in locked mode? (Locking clip, switched retractor or locking latch plate).

  • Is locking clip used correctly?

  • Is safety belt routed correctly? (Belt Path)

  • Is Child within Manufacturer's Recommended height and weight range(s)?

  • Is child seated in appropriate location in vehicle?

  • If present, is carrier handle in correct position for travel?

ON DEPARTURE

  • 18.) Child/ CSS Location in Vehicle? (D = Driver, X = CSS)

  • 19.) CSS Installed Using (select all that apply)

    • No CSS
    • Uninstalled
    • Seatbelt
    • Tether
    • Lower Anchors
    • Integrated Seat (Mark - Go to 25)

  • 20.) Coalition Provided a New CSS

  • 21.) Restraint Type?

    • Rear Facing Only w/o Base
    • Rear Facing Only with Base
    • Base Only
    • Rear Facing Convertible
    • Forward Facing with Harness
    • Belt Positioning Booster
    • Lap/Shoulder (Go to #17)
    • Lap Only (Go to #17)
    • Car Bed
    • Vest

  • 22.) CSS Manufacturer

  • 23.) Model Number

  • Manufacture Date

  • 25.) All Corrections Made?

  • 26.) CSS/Vehicle Compatible

  • 27.) Education Materials Given

  • Picture of Seat #1 upon completion of inspection

  • Technician Discussed: (Select all that apply)

  • 28.) Airbags

  • 29.) Unused Seatbelt

  • 30.) Projectiles

  • 31.) Unattended children in or around cars.

  • 32.) Next steps

Caregiver Sign Off

  • 33.) I harnessed child in CSS

  • 34.) I participated/installed CSS today

  • Caregiver Initials

  • Comments

Replaced/Donated Seats

  • Was CRS Replaced or donated for child #1?

  • If replaced, what type?

  • Manufacturer:

  • Model Name:

  • Model Number:

  • Manufacture Date: mm/dd/yyyy

  • Was CRS Replaced or donated for child #2?

  • If replaced, what type?

  • Manufacturer:

  • Model Name:

  • Model Number:

  • Manufacture Date: mm/dd/yyyy

  • Was CRS Replaced or donated for child #3?

  • If replaced, what type?

  • Manufacturer:

  • Model Name:

  • Model Number:

  • Manufacture Date: mm/dd/yyyy

  • Was CRS Replaced or donated for child #4?

  • If replaced, what type?

  • Manufacturer:

  • Model Name:

  • Model Number:

  • Manufacture Date: mm/dd/yyyy

Follow-Up

  • Were ALL Misuses corrected?

  • Parent was able to properly install car seats?

  • Comments

  • Technician Signature

  • Parent Signature

CPS Technician information:

  • Technician name:

  • Technician certification number:

  • Technician phone number:

  • Technician e-mail:

Child Passenger Safety Inspection Form
JS

Child Passenger Safety Inspection Form

Safe Kids Wyoming

Use this Template
The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.

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