Child Restraint Checkup Form

• I/We understand the car seat check up provided today is done in the interest of community safety. The sponsoring organizations/technicians will not and cannot guarantee any child seat checked today is constructed without defects. I/We understand to have full protective benefits of a child car seat the child must be properly secured in the seat and the seat must be attached to the vehicle in accordance with the manufacturer's and vehicle's instructions. I/We agree to hold harmless the sponsoring organizations, workers, and technicians from any present and future liability and/or damages for injuries including death, arising from or growing out of the assistance/information received today.

  Off

  On

• Date and time

  Date
• Location
  Address

Personal information on caregiver

• Name:

• Address:

• Phone number:

• Email address:

• Vehicle
  

Vehicle

Vehicle information

• Year:

• Make:

• Model:

Child

Child's information

• Name:

• Age:

• Weight:

• Height:

Car seat info on arrival:

• Photo on arrival if installed.

  Media

• Car seat is

  Installed

  Uninstalled

• Car seat received

  New

  Used

• Is the seat free of crashes?

  Yes

  No

  Maybe

  Unknown

• Is the seat free of frontal airbags?

  Yes

  No

• Vehicle seat faces forward?

  Yes

  No

• Seating position has side airbag? If so, discuss with caregiver.

  Yes

  No

• Location in vehicle

  Select Front center Front passenger Second row driver Second row center Second row passenger Third row driver Third row center Third row passenger

  • Front center
  • Front passenger
  • Second row driver
  • Second row center
  • Second row passenger
  • Third row driver
  • Third row center
  • Third row passenger

Child arrives in:

• Rear facing seat?

  Yes

  No

• Child's age and/or weight appropriate?

  Yes

  No

• Shell at least 1" above head, or required amount?

  Yes

  No

• Shoulder straps in correct slots?

  Yes

  No

• Seat appropriately reclined?

  Yes

  No

• Handle position correct?

  Yes

  No

  N/A

• Harness adjusted snugly?

  Yes

  No

• Chest clip present?

  Yes

  No

  N/A

• Chest clip threaded properly?

  Yes

  No

  N/A

• Chest clip at the armpit level?

  Yes

  No

  N/A

• Converted seat to forward facing?

  Yes

  No

• Maximum weight limit rear facing?

• Forward facing seat?

  Yes

  No

• Child's age and/or weight appropriate?

  Yes

  No

• Ears at or below top of shell?

  Yes

  No

• Shoulder straps in correct slots?

  Yes

  No

• Seat appropriately reclined, if necessary?

  Yes

  No

• Harness adjusted snugly?

  Yes

  No

• Chest clip present?

  Yes

  No

  N/A

• Chest clip threaded properly?

  Yes

  No

  N/A

• Chest clip at the armpit level?

  Yes

  No

  N/A

• Tethered?

  Yes

  No

• Tether can be retrofitted?

  Yes

  No

• Tether part and information

• Properly adjusted?

  Yes

  No

  N/A

• Attached to tether anchor?

  Yes

  No

  N/A

• Moved child to rear facing?

  Yes

  No

• Moved child to booster?

  Yes

  No

• Maximum weight limit forward facing?

• Belt positioning booster?

  Yes

  No

• Child's age and/or weight appropriate?

  Yes

  No

• Ears at or below top of whiplash protection?

  Yes

  No

• Uses lap and shoulder belt?

  Yes

  No

• Shoulder portion fits appropriately?

  Yes

  No

• Lap portion fits appropriately?

  Yes

  No

• Moved child to harnessed seat?

  Yes

  No

• Moved child to seat belt?

  Yes

  No

• Maximum weight limit?

• Seat belt?

  Yes

  No

• Uses lap and shoulder belt?

  Yes

  No

• Child's bottom is against seat back?

  Yes

  No

• Child's knees bend at the edge of the seat and their feet reach the floor?

  Yes

  No

• Lap portion fits appropriately?

  Yes

  No

• Shoulder portion fits appropriately?

  Yes

  No

• Ears at or below top of whiplash protection?

  Yes

  No

• Moved child to booster?

  Yes

  No

• Moved child to harnessed seat?

  Yes

  No

• Photo on departure

  Media

Installation:

• Lower Anchors

• Seat belt

• Tether

• Seat belt or lower connectors properly routed?

  Yes

  No

  N/A

• Seat secured with less than 1" of movement at the belt path?

  Yes

  No

  N/A

• Locking clip/lock off mechanism used if needed?

  Yes

  No

  N/A

• Locking clip/lock off mechanism used correctly?

  Yes

  No

  N/A

• Seatbelt free of inappropriate locking clip?

  Yes

  No

  N/A

• Seatbelt

  Lap and shoulder

  Lap only

• Retractor

  Switchable

  ELR

  No retractor

  ALR

• Latch plate?

  Free sliding

  Locking

  Sewn on

• Lower anchors

• In LATCH position?

  Yes

  No

  N/A

• Used correctly?

  Yes

  No

  N/A

Restraint information

• Manufacturer

• Model name

• Model number

• Date of manufacture

• Has instructions?

  Yes

  No

• Seat is within acceptable lifespan?

  Yes

  No

• Free from recalls

  Yes

  No

• Recalls corrected?

  Yes

  No

  N/A

• Recall fix/phone number:

• Harness:

• Harness is threaded properly?

  Yes

  No

  N/A

• Harness lies flat and is not torn or frayed?

  Yes

  No

  N/A

• Buckle mechanism appears to open and lock appropriately?

  Yes

  No

  N/A

• Add on products are acceptable?

  Yes

  No

  N/A

• Technician discussed

• Airbags

• Unused seatbelt

• Projectiles (including pets)

• Unattended children in and around cars

• Next steps

Caregiver

• Caregiver harnessed child/doll?

  Yes

  No

  N/A

• Caregiver participated in check today?

  Yes

  No

  N/A

• Caregiver signature

  Sign

Technician information

• Name

• Email

• Tech ID

• Technician signature

  Sign