Child Passenger Safety Inspection From

• Document No.

• Type of event

  Drop-in

  Wednesday event

  Special event

  Private appointment

• Station

  Select 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 HQ Other

  • 31
  • 32
  • 33
  • 34
  • 35
  • 36
  • 37
  • 38
  • 39
  • 40
  • 41
  • 42
  • 43
  • 44
  • 45
  • 46
  • 47
  • HQ
  • Other

• Conducted on

  Date
• Other location
  Address

CPS Technician information:

• Technician name:

Participant Information:

• Driver's name

• Driver's address
  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.<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.

  Yes

  No

  N/A

• Participant Signature

  Sign

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?

  Yes

  No

  N/A

• 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

• Child's age

• Child's weight

• Child height

• CRS type?

• Manufacturer

• Model name

• Model Number:

• Manufacture Date: mm/dd/yyyy

• RECALL List checked?

  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

• CSS on Recall List?

  Yes

  No

  N/A

• Participant Notified?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• New install?

  Yes

  No

  N/A

• Is child seated in appropriate location in vehicle?

  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 seat belt or Lower anchors used correctly

  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 or Lower anchors routed correctly? (Belt Path)

  Yes

  No

  N/A

• Is tether correctly used?

  Yes

  No

  N/A

• Is CSS tightly installed? (1" test)

  Yes

  No

  N/A

• Is harness in correct harness slots?

  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

• Is harness threaded correctly?

  Yes

  No

  N/A

• Child 2

  Yes

  No

  N/A

• Child Present?

  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

• Picture of Seat as it was found

  Media

• Manufacturer:

• Model Name:

• Model Number:

• Manufacture Date: mm/dd/yyyy

• RECALL List checked?

  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

• CSS on Recall List?

  Yes

  No

  N/A

• Participant Notified?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• New install?

  Yes

  No

  N/A

• Is child seated in appropriate location in vehicle?

  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 Lower anchors routed correctly? (Belt Path)

  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 of lower anchors routed correctly? (belt path)

  Yes

  No

  N/A

• Is tether correctly used?

  Yes

  No

  N/A

• Is CSS tightly installed? (1" test)

  Yes

  No

  N/A

• Is harness in correct harness slots?

  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

• Is harness threaded correctly?

  Yes

  No

  N/A

• Child 3

  Yes

  No

  N/A

• Child Present?

  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

• Picture of Seat as it was found

  Media

• Manufacturer:

• Model Name:

• Model Number:

• Manufacture Date: mm/dd/yyyy

• RECALL List checked?

  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

• CSS on Recall List?

  Yes

  No

  N/A

• Participant Notified?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• New install?

  Yes

  No

  N/A

• Is child seated in appropriate location in vehicle?

  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 seat belt or lower anchors used correctly?

  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 or lower anchors routed correctly? (Belt path)

  Yes

  No

  N/A

• Is tether correctly used?

  Yes

  No

  N/A

• Is CSS tightly installed? (1" test)

  Yes

  No

  N/A

• Is harness in correct harness slots?

  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

• Is Harness threaded correctly?

  Yes

  No

  N/A

• Child 4

  Yes

  No

  N/A

• Child Present?

  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

• Picture of Seat as it was found

  Media

• Manufacturer:

• Model Name:

• Model Number:

• Manufacture Date: mm/dd/yyyy

• RECALL List checked?

  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

• CSS on Recall List?

  Yes

  No

  N/A

• Participant Notified?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• New install?

  Yes

  No

  N/A

• Is child seated in appropriate location in vehicle?

  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 seat belt or lower anchors used correctly?

  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 CSS tightly installed? (1" test)

  Yes

  No

  N/A

• Is harness in correct harness slots?

  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

• Is harness threaded correctly?

  Yes

  No

  N/A

Follow-Up

• Were ALL Misuses corrected?

  Yes

  No

  N/A

• Parent was able to properly install car seats?

  Yes

  No

  N/A

• Comments

• Technician Signature

  Sign