Audit

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.

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
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
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)

20.) Coalition Provided a New CSS

21.) Restraint Type?

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
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)

20.) Coalition Provided a New CSS

21.) Restraint Type?

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
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)

20.) Coalition Provided a New CSS

21.) Restraint Type?

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:

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.