Audit

CPS Technician information:

Technician name:

Participant Information:

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

How many children in seatbelts?

How many adults in seatbelts?

How many child safety seats in the vehicle?

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

Airbags
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?

Child's age

Child's weight

Child height

CRS type?

Manufacturer

Model name

Model Number:

Manufacture Date: mm/dd/yyyy

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

CSS on Recall List?

Participant Notified?

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

New install?

Is child seated in appropriate location in vehicle?

Is seat facing correct direction?

Is seat installed at the correct angle?

Is seat belt or Lower anchors used correctly

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

Is locking clip used correctly?

Is safety belt or Lower anchors routed correctly? (Belt Path)

Is tether correctly used?

Is CSS tightly installed? (1" test)

Is harness in correct harness slots?

Are harness straps snug?

Is harness retainer clip at armpit level?

Is harness free of tears or twists?

Is harness threaded correctly?

Child 2

Child Present?

Child's Age

Child's Weight (lbs)

Child's Height (Inches)

CRS Type
Picture of Seat as it was found

Manufacturer:

Model Name:

Model Number:

Manufacture Date: mm/dd/yyyy

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

CSS on Recall List?

Participant Notified?

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

New install?

Is child seated in appropriate location in vehicle?

Is seat facing correct direction?

Is seat installed at the correct angle?

Is safety belt Lower anchors routed correctly? (Belt Path)

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

Is locking clip used correctly?

Is safety belt of lower anchors routed correctly? (belt path)

Is tether correctly used?

Is CSS tightly installed? (1" test)

Is harness in correct harness slots?

Are harness straps snug?

Is harness retainer clip at armpit level?

Is harness free of tears or twists?

Is harness threaded correctly?

Child 3

Child Present?

Child's Age

Child's Weight (lbs)

Child's Height (Inches)

CRS Type
Picture of Seat as it was found

Manufacturer:

Model Name:

Model Number:

Manufacture Date: mm/dd/yyyy

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

CSS on Recall List?

Participant Notified?

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

New install?

Is child seated in appropriate location in vehicle?

Is seat facing correct direction?

Is seat installed at the correct angle?

Is seat belt or lower anchors used correctly?

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

Is locking clip used correctly?

Is safety belt or lower anchors routed correctly? (Belt path)

Is tether correctly used?

Is CSS tightly installed? (1" test)

Is harness in correct harness slots?

Are harness straps snug?

Is harness retainer clip at armpit level?

Is harness free of tears or twists?

Is Harness threaded correctly?

Child 4

Child Present?

Child's Age

Child's Weight (lbs)

Child's Height (Inches)

CRS Type
Picture of Seat as it was found

Manufacturer:

Model Name:

Model Number:

Manufacture Date: mm/dd/yyyy

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

CSS on Recall List?

Participant Notified?

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

New install?

Is child seated in appropriate location in vehicle?

Is seat facing correct direction?

Is seat installed at the correct angle?

Is seat belt or lower anchors used correctly?

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 CSS tightly installed? (1" test)

Is harness in correct harness slots?

Are harness straps snug?

Is harness retainer clip at armpit level?

Is harness free of tears or twists?

Is harness threaded correctly?

Follow-Up

Were ALL Misuses corrected?

Parent was able to properly install car seats?

Comments

Technician 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.