Florida OPRC Child Passenger Safety Inspection Form - REVISED

• Technician Information

• Technician Name

• Email Address

• Instructor Supplier

• Additional Personnel

• County

• Agency

• Technician Number

• Phone Number

• Location
  Address

• Conducted on

  Date

Participant Information

• Driver Name

• Phone Number

• Email Address

• WIC?

  Off

  On

• WIC Number

• Name (if different from driver)

• Relationship to Child

  Parent/Gaurdian

  Grandparent

  Other

• Expectant Mom?

  Yes

  No

  N/A

Waiver of Liability

• Waiver of Liability:<br><br>I understand that the sole purpose of this program is to reduce the incidence of improper installation and use of child safety seats or child restraint devices (CRD); 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 be 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 of 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

• Type Name

• Participant Signature

  Sign

Vehicle Information

• Make

  Select Acura Audi BMW Buick Cadillac Chevrolet Chrysler Dodge Ford GMC Honda Hummer Hyundai Infiniti Isuzu Jaguar Jeep Kia Motors Lexus Lincoln Mazda Mercedes-Benz Mercury Mitsubishi Nissan Oldsmobile Pontiac Saab Saturn Subaru Suzuki Toyota Volkswagon Volvo

  • Acura
  • Audi
  • BMW
  • Buick
  • Cadillac
  • Chevrolet
  • Chrysler
  • Dodge
  • Ford
  • GMC
  • Honda
  • Hummer
  • Hyundai
  • Infiniti
  • Isuzu
  • Jaguar
  • Jeep
  • Kia Motors
  • Lexus
  • Lincoln
  • Mazda
  • Mercedes-Benz
  • Mercury
  • Mitsubishi
  • Nissan
  • Oldsmobile
  • Pontiac
  • Saab
  • Saturn
  • Subaru
  • Suzuki
  • Toyota
  • Volkswagon
  • Volvo

• Model

• Year

  Select 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

  • 1970
  • 1971
  • 1972
  • 1973
  • 1974
  • 1975
  • 1976
  • 1977
  • 1978
  • 1979
  • 1980
  • 1981
  • 1982
  • 1983
  • 1984
  • 1985
  • 1986
  • 1987
  • 1988
  • 1989
  • 1990
  • 1991
  • 1992
  • 1993
  • 1994
  • 1995
  • 1996
  • 1997
  • 1998
  • 1999
  • 2000
  • 2001
  • 2002
  • 2003
  • 2004
  • 2005
  • 2006
  • 2007
  • 2008
  • 2009
  • 2010
  • 2011
  • 2012
  • 2013
  • 2014
  • 2015
  • 2016

• Airbags

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

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

Occupants

• Number of Occupants

• More than 7?

  Off

  On

• Number of Occupants

Location of Occupants on Arrival

• Passenger

  Off

  On

• Type of Passenger

  Select A T C1 C2 C3 C4

  • A
  • T
  • C1
  • C2
  • C3
  • C4

• Driver-Middle

  Off

  On

• Type of Passenger

  Select A T C1 C2 C3 C4

  • A
  • T
  • C1
  • C2
  • C3
  • C4

• Passenger-Middle

  Off

  On

• Type of Passenger

  Select A T C1 C2 C3 C4

  • A
  • T
  • C1
  • C2
  • C3
  • C4

• Driver-Rear

  Off

  On

• Type of Passenger

  Select A T C1 C2 C3 C4

  • A
  • T
  • C1
  • C2
  • C3
  • C4

• Passenger-Rear

  Off

  On

• Type of Passenger

  Select A T C1 C2 C3 C4

  • A
  • T
  • C1
  • C2
  • C3
  • C4

On Arrival (Inspection of child/seat - complete as found)

• Click "Add Child" to add a new child.

Child

• 23 months or younger?

  Off

  On

• Age

  Select Unborn 1 month or less 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 12 months 13 months 14 months 15 months 16 months 17 months 18 months 19 months 20 months 21 months 22 months 23 months

  • Unborn
  • 1 month or less
  • 2 months
  • 3 months
  • 4 months
  • 5 months
  • 6 months
  • 7 months
  • 8 months
  • 9 months
  • 10 months
  • 11 months
  • 12 months
  • 13 months
  • 14 months
  • 15 months
  • 16 months
  • 17 months
  • 18 months
  • 19 months
  • 20 months
  • 21 months
  • 22 months
  • 23 months

• 2 years or older?

  Off

  On

• Age

  Select 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years

  • 2 years
  • 3 years
  • 4 years
  • 5 years
  • 6 years
  • 7 years
  • 8 years
  • 9 years
  • 10 years
  • 11 years
  • 12 years

• CRD?

  Installed

  Not Installed but Present

  None Present

• Purchase OPRC Seat

• Select the Seat Purchased.

  Titan 50

  Titan 65

  Secure Kid 300

  Big Kid BPB

• Purchase Non-OPRC Seat

• Manufacturer

• Model

• Rental of Special Needs Restraint

• Manufacturer

  Select Angel Guard Dorel Merritt Manufacturing Snug Seat EZ-On Vests Columbia Medical

  • Angel Guard
  • Dorel
  • Merritt Manufacturing
  • Snug Seat
  • EZ-On Vests
  • Columbia Medical

• Model

  Select Angel Ride Dream Ride Ultra HOPE car bed Roosevelt HIPPO Columbia 2000 Columbia 2500 Spirit Modified EZ-ON Vest Upright EZ-ON Vest

  • Angel Ride
  • Dream Ride
  • Ultra
  • HOPE car bed
  • Roosevelt
  • HIPPO
  • Columbia 2000
  • Columbia 2500
  • Spirit
  • Modified EZ-ON Vest
  • Upright EZ-ON Vest

• Date of Manufacture

• Model #

• Special Needs ID

• WIC or Medicaid #

• History Known?

  Yes

  No

• Parent chooses to purchase seat?

  Yes

  No

• Parent chooses to install seat as is.

• Parent leaves with no install.

• Is the parent the original owner of the CRD?

  Yes

  No

• Installed Using:

  Select Seatbelt LATCH Tether Integrated Seat

  • Seatbelt
  • LATCH
  • Tether
  • Integrated Seat

• CRD Type

  Select RF only w/o base Base only RF only w/ base RF convertible FF w/ harness BP booster Lap/Shoulder Lap only Car bed Vest

  • RF only w/o base
  • Base only
  • RF only w/ base
  • RF convertible
  • FF w/ harness
  • BP booster
  • Lap/Shoulder
  • Lap only
  • Car bed
  • Vest

• CRD Manufacturer

  Select Baby Trend Britax Chicco Combi Evenflo Graco Harmony Magna/Clek Orbit Peg Perego Recaro Sunshine Kids/Diono Learning Curve - 1st Years Dorel (Cosco, Edie Bauer, Safety 1st, Maxi Cosi)

  • Baby Trend
  • Britax
  • Chicco
  • Combi
  • Evenflo
  • Graco
  • Harmony
  • Magna/Clek
  • Orbit
  • Peg Perego
  • Recaro
  • Sunshine Kids/Diono
  • Learning Curve - 1st Years
  • Dorel (Cosco, Edie Bauer, Safety 1st, Maxi Cosi)

• Other (if not listed)

• Model Name

• Date of Manufacture

• Model Number

• History Known?

  Yes

  No

• Caregiver/Parent advised by tech to replace seat?

  Off

  On

• Parent chooses to purchase seat

  Yes

  No

• Parent chooses to install seat as is.

• Parent leaves with no install.

Recall/Expired CRD

• CRD past the expiration date

  Off

  On

• Was the parent/caregiver notified?

  Yes

  No

• CRD is on recall list

  Off

  On

• Was the parent/caregiver notified?

  Yes

  No

Findings

• Selection (Height, Weight, Manufacturer's Instructions/Labels, Special Health Care Needs)

  All Correct

  Errors Found

• Check all that apply.

• Child is not within recommended height and weight ranges.

• Manufacturer's Instructions are not present.

• Manufacturer's Labels are not present.

• CRD not in good working order with all parts present.

• Child Placement

  All Correct

  Errors Found

• Check all that apply.

• If present, carry handle is in wrong position for travel.

• Add-ons are present.

• Child is place incorrectly in CRD.

• Harness is threaded incorrectly according to child's height, weight, and direction.

• Retainer clip is not used correctly.

• Harness is not snug on child.

• Seat Installation

  All Correct

  Errors Found

• Check all that apply.

• Seat is secured in an inappropriate location in the vehicle.

• Seat is facing the incorrect direction for the child.

• Seat angle is incorrect according to the Manufacturer's Directions.

• CRD Installed using:

  Seatbelt

  LATCH

  Tether

• Yes

  No

• Present but not used

• Incorrect anchor points used

• Attachment upside-down on anchor point – see LATCH manual

• Seatbelt is in the locked mode.

• Locking Latchplate

• Switched Mode

• Locking Clip

• Seatbelt is routed correctly on the CRD.

• D-Ring is present on shoulder belt and is in the lowers position for installation.

• CRD is secured to the vehicle and meets the "1" test.

• Is LATCH used correctly?

  Yes

  No

• Attached to incorrect anchor points

• Attached upside-down

• Not secured, does not meet "1" test

• Use seatbelt and LATCH together when not allowed by manufacturers

Departure

• All corrections were made.

• Why not?

• CRD was purchased/replaced

• OPRC seat sold.

• Amount ($)

• Non-OPRC seat sold.

• Parent provided seat.

• Check all that apply:

• No misuse found upon arrival of installed car seat.

• New install (no previous seat being used (installed) in the vehicle for this child).

• Parent able to properly install the CRD.

• The CRD was placed in another location in the vehicle.

• Select the location:

  Select A T C1 C2 C3 C4

  • A
  • T
  • C1
  • C2
  • C3
  • C4

• Parent/caregiver participated by installed seat and harnessing child (please initial)

  Sign

• Donation Given ($)

• Technician Signature

  Sign

• Senior Checker (printed name, if applicable)

• Senior Checker Signature (if applicable)

  Sign