Participant info

Participant Information

Name:

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, make and model

# of child safety seats in vehicle

# of children is seat belts in vehicle

# of adults in seat belts in vehicle

Airbags

Audit

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
Inspection Seat/Child (COMPLETE AS SEAT WAS FOUND)

Child 1

Child Present?

Expectant Mom?

Child's Age

Child's Weight (lbs)

Child's Height (Inches)

CRS Type

Manufacturer:

Model name:

Model number:

Manufacture Date: mm/dd/yyyy

Picture of Seat as it was found

Is this a new installation?

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

CSS on Recall List?

Participant Notified?

Problem corrected?

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?)

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

Is the car seat crash-free?

Is the history of the car seat known?

Are there any installation errors?

Is child seated in appropriate location in vehicle?

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

Is seat facing correct direction?

Is seat installed at the correct angle?

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 tether correctly used?

Is LATCH correctly used?

Are there any harnessing errors?

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?

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

Was CRS Replaced or donated for child #1?

If replaced, what type?

Manufacturer:

Model name:

Model number:

Manufacture Date: mm/dd/yyyy

Picture of Seat #1 upon completion of inspection

Child 2

Child Present?

Expectant Mom?

Child's Age

Child's Weight (lbs)

Child's Height (Inches)

CRS Type

Manufacturer:

Model name:

Model number:

Manufacture Date: mm/dd/yyyy

Picture of Seat as it was found

Is this a new installation?

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

CSS on Recall List?

Participant Notified?

Problem corrected?

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?)

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

Is the car seat crash-free?

Is the history of the car seat known?

Are there any installation errors?

Is child seated in appropriate location in vehicle?

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

Is seat facing correct direction?

Is seat installed at the correct angle?

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 tether correctly used?

Is LATCH correctly used?

Are there any harnessing errors?

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?

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

Was CRS Replaced or donated for child #2?

If replaced, what type?

Manufacturer:

Model name:

Model number:

Manufacture Date: mm/dd/yyyy

Picture of Seat #2 upon completion of inspection

Child 3

Child Present?

Expectant Mom?

Child's Age

Child's Weight (lbs)

Child's Height (Inches)

CRS Type

Manufacturer:

Model name:

Model number:

Manufacture Date: mm/dd/yyyy

Picture of Seat as it was found

Is this a new installation?

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

CSS on Recall List?

Participant Notified?

Problem corrected?

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?)

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

Is the car seat crash-free?

Is the history of the car seat known?

Are there any installation errors?

Is child seated in appropriate location in vehicle?

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

Is seat facing correct direction?

Is seat installed at the correct angle?

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 tether correctly used?

Is LATCH correctly used?

Are there any harnessing errors?

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?

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

Was CRS Replaced or donated for child #3?

If replaced, what type?

Manufacturer:

Model name:

Model number:

Manufacture Date: mm/dd/yyyy

Picture of Seat #3 upon completion of inspection

Child 4

Child Present?

Expectant Mom?

Child's Age

Child's Weight (lbs)

Child's Height (Inches)

CRS Type

Manufacturer:

Model name:

Model number:

Manufacture Date: mm/dd/yyyy

Picture of Seat as it was found

Is this a new installation?

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

CSS on Recall List?

Participant Notified?

Problem corrected?

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?)

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

Is the car seat crash-free?

Is the history of the car seat known?

Are there any installation errors?

Is child seated in appropriate location in vehicle?

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

Is seat facing correct direction?

Is seat installed at the correct angle?

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 tether correctly used?

Is LATCH correctly used?

Are there any harnessing errors?

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?

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

Was CRS Replaced or donated for child #4?

If replaced, what type?

Manufacturer:

Model name:

Model number:

Manufacture Date: mm/dd/yyyy

Picture of Seat #4 upon completion of inspection

Follow-up

Follow-up

We're all misuses corrected?

Was parent able to properly install the car seat?

Comments:

Technician signature
Participant signature
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.