Child Passenger Safety Inspection Form

• Audit Title

• Client / Site

• Conducted on

  Date
• Location
  Address

• Technician name

• Technician number

• Technician phone and/or email

Participant Information

• Name:

• Address:

• Phone number:

• E-mail:

• Relationship to child:

  Parent/guardian

  Grandparent

  Expectant Parent

  Day Care

  Other

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:

  Sign

Vehicle information:

• Vehicle year, make and model

• # of child safety seats in vehicle

• # of children is seat belts in vehicle

• # of adults in seat belts in vehicle

• Airbags

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

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

Location of Occupants

• Location of Occupants: D=Driver, X=Found, M=Moved to. Use C1, C2 for Children/T1, T2 for Teens/A1, A2 for Adults

  Drawing

Inspection Seat/Child (COMPLETE AS SEAT WAS FOUND)

• Child 1

  Yes

  No

  N/A

• Child Present?

  Yes

  No

  N/A

• Expectant Mom?

  Yes

  No

  N/A

• Child's Age

• Child's Weight (lbs)

• Child's Height (Inches)

• CRS Type

  Select None Infant only Infant only w/ Base Convertible - Rear Facing Convertible - Forward Facing Combination Belt Positioning Booster

  • None
  • Infant only
  • Infant only w/ Base
  • Convertible - Rear Facing
  • Convertible - Forward Facing
  • Combination
  • Belt Positioning Booster

• Manufacturer:

• Model name:

• Model number:

• Manufacture Date: mm/dd/yyyy

• Picture of Seat as it was found

  Media

• Is this a new installation?

  Yes

  No

  N/A

• Since this is a new installation only mark selection or recalls as errors.

• CSS on Recall List?

  Yes

  No

  N/A

• Participant Notified?

  Yes

  No

  N/A

• Problem corrected?

  Yes

  No

  N/A

• 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

• Are there any selection errors? (Right seat, crashes, history?)

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is the car seat crash-free?

  Yes

  No

  N/A

• Is the history of the car seat known?

  Yes

  No

  N/A

• Are there any installation errors?

  Yes

  No

  N/A

• Is child seated in appropriate location in vehicle?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is seat facing correct direction?

  Yes

  No

  N/A

• Is seat installed at the correct angle?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is locking clip used correctly?

  Yes

  No

  N/A

• Is safety belt routed correctly? (Belt Path)

  Yes

  No

  N/A

• Is tether correctly used?

  Yes

  No

  N/A

• Is LATCH correctly used?

  Yes

  No

  N/A

• Are there any harnessing errors?

  Yes

  No

  N/A

• Is harness in correct harness slots?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are harness straps snug?

  Yes

  No

  N/A

• Is harness retainer clip at armpit level?

  Yes

  No

  N/A

• Is harness free of tears or twists?

  Yes

  No

  N/A

• If "D" ring is present is harness in locked mode?

  Yes

  No

  N/A

• Was CRS Replaced or donated for child #1?

  Yes

  No

  N/A

• If replaced, what type?

  Infant Only

  Convertible

  Combination

  Belt Positioning Booster

• Manufacturer:

• Model name:

• Model number:

• Manufacture Date: mm/dd/yyyy

• Picture of Seat #1 upon completion of inspection

  Media

• Child 2

  Yes

  No

  N/A

• Child Present?

  Yes

  No

  N/A

• Expectant Mom?

  Yes

  No

  N/A

• Child's Age

• Child's Weight (lbs)

• Child's Height (Inches)

• CRS Type

  Select None Infant only Infant only w/ Base Convertible - Rear Facing Convertible - Forward Facing Combination Belt Positioning Booster

  • None
  • Infant only
  • Infant only w/ Base
  • Convertible - Rear Facing
  • Convertible - Forward Facing
  • Combination
  • Belt Positioning Booster

• Manufacturer:

• Model name:

• Model number:

• Manufacture Date: mm/dd/yyyy

• Picture of Seat as it was found

  Media

• Is this a new installation?

  Yes

  No

  N/A

• Since this is a new installation only mark selection or recalls as errors.

• CSS on Recall List?

  Yes

  No

  N/A

• Participant Notified?

  Yes

  No

  N/A

• Problem corrected?

  Yes

  No

  N/A

• 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

• Are there any selection errors? (Right seat, crashes, history?)

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is the car seat crash-free?

  Yes

  No

  N/A

• Is the history of the car seat known?

  Yes

  No

  N/A

• Are there any installation errors?

  Yes

  No

  N/A

• Is child seated in appropriate location in vehicle?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is seat facing correct direction?

  Yes

  No

  N/A

• Is seat installed at the correct angle?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is locking clip used correctly?

  Yes

  No

  N/A

• Is safety belt routed correctly? (Belt Path)

  Yes

  No

  N/A

• Is tether correctly used?

  Yes

  No

  N/A

• Is LATCH correctly used?

  Yes

  No

  N/A

• Are there any harnessing errors?

  Yes

  No

  N/A

• Is harness in correct harness slots?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are harness straps snug?

  Yes

  No

  N/A

• Is harness retainer clip at armpit level?

  Yes

  No

  N/A

• Is harness free of tears or twists?

  Yes

  No

  N/A

• If "D" ring is present is harness in locked mode?

  Yes

  No

  N/A

• Was CRS Replaced or donated for child #2?

  Yes

  No

  N/A

• If replaced, what type?

  Infant Only

  Convertible

  Combination

  Belt Positioning Booster

• Manufacturer:

• Model name:

• Model number:

• Manufacture Date: mm/dd/yyyy

• Picture of Seat #2 upon completion of inspection

  Media

• Child 3

  Yes

  No

  N/A

• Child Present?

  Yes

  No

  N/A

• Expectant Mom?

  Yes

  No

  N/A

• Child's Age

• Child's Weight (lbs)

• Child's Height (Inches)

• CRS Type

  Select None Infant only Infant only w/ Base Convertible - Rear Facing Convertible - Forward Facing Combination Belt Positioning Booster

  • None
  • Infant only
  • Infant only w/ Base
  • Convertible - Rear Facing
  • Convertible - Forward Facing
  • Combination
  • Belt Positioning Booster

• Manufacturer:

• Model name:

• Model number:

• Manufacture Date: mm/dd/yyyy

• Picture of Seat as it was found

  Media

• Is this a new installation?

  Yes

  No

  N/A

• Since this is a new installation only mark selection or recalls as errors.

• CSS on Recall List?

  Yes

  No

  N/A

• Participant Notified?

  Yes

  No

  N/A

• Problem corrected?

  Yes

  No

  N/A

• 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

• Are there any selection errors? (Right seat, crashes, history?)

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is the car seat crash-free?

  Yes

  No

  N/A

• Is the history of the car seat known?

  Yes

  No

  N/A

• Are there any installation errors?

  Yes

  No

  N/A

• Is child seated in appropriate location in vehicle?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is seat facing correct direction?

  Yes

  No

  N/A

• Is seat installed at the correct angle?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is locking clip used correctly?

  Yes

  No

  N/A

• Is safety belt routed correctly? (Belt Path)

  Yes

  No

  N/A

• Is tether correctly used?

  Yes

  No

  N/A

• Is LATCH correctly used?

  Yes

  No

  N/A

• Are there any harnessing errors?

  Yes

  No

  N/A

• Is harness in correct harness slots?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are harness straps snug?

  Yes

  No

  N/A

• Is harness retainer clip at armpit level?

  Yes

  No

  N/A

• Is harness free of tears or twists?

  Yes

  No

  N/A

• If "D" ring is present is harness in locked mode?

  Yes

  No

  N/A

• Was CRS Replaced or donated for child #3?

  Yes

  No

  N/A

• If replaced, what type?

  Infant Only

  Convertible

  Combination

  Belt Positioning Booster

• Manufacturer:

• Model name:

• Model number:

• Manufacture Date: mm/dd/yyyy

• Picture of Seat #3 upon completion of inspection

  Media

• Child 4

  Yes

  No

  N/A

• Child Present?

  Yes

  No

  N/A

• Expectant Mom?

  Yes

  No

  N/A

• Child's Age

• Child's Weight (lbs)

• Child's Height (Inches)

• CRS Type

  Select None Infant only Infant only w/ Base Convertible - Rear Facing Convertible - Forward Facing Combination Belt Positioning Booster

  • None
  • Infant only
  • Infant only w/ Base
  • Convertible - Rear Facing
  • Convertible - Forward Facing
  • Combination
  • Belt Positioning Booster

• Manufacturer:

• Model name:

• Model number:

• Manufacture Date: mm/dd/yyyy

• Picture of Seat as it was found

  Media

• Is this a new installation?

  Yes

  No

  N/A

• Since this is a new installation only mark selection or recalls as errors.

• CSS on Recall List?

  Yes

  No

  N/A

• Participant Notified?

  Yes

  No

  N/A

• Problem corrected?

  Yes

  No

  N/A

• 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

• Are there any selection errors? (Right seat, crashes, history?)

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is the car seat crash-free?

  Yes

  No

  N/A

• Is the history of the car seat known?

  Yes

  No

  N/A

• Are there any installation errors?

  Yes

  No

  N/A

• Is child seated in appropriate location in vehicle?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is seat facing correct direction?

  Yes

  No

  N/A

• Is seat installed at the correct angle?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is locking clip used correctly?

  Yes

  No

  N/A

• Is safety belt routed correctly? (Belt Path)

  Yes

  No

  N/A

• Is tether correctly used?

  Yes

  No

  N/A

• Is LATCH correctly used?

  Yes

  No

  N/A

• Are there any harnessing errors?

  Yes

  No

  N/A

• Is harness in correct harness slots?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are harness straps snug?

  Yes

  No

  N/A

• Is harness retainer clip at armpit level?

  Yes

  No

  N/A

• Is harness free of tears or twists?

  Yes

  No

  N/A

• If "D" ring is present is harness in locked mode?

  Yes

  No

  N/A

• Was CRS Replaced or donated for child #4?

  Yes

  No

  N/A

• If replaced, what type?

  Infant Only

  Convertible

  Combination

  Belt Positioning Booster

• Manufacturer:

• Model name:

• Model number:

• Manufacture Date: mm/dd/yyyy

• Picture of Seat #4 upon completion of inspection

  Media

Follow-up

• We're all misuses corrected?

  Yes

  No

  N/A

• Was parent able to properly install the car seat?

  Yes

  No

  N/A

• Comments:

• Technician signature

  Sign

• Participant signature

  Sign