Participant Information

  • Driver Name

  • Phone Number

  • Email Address

  • WIC?

  • WIC Number

  • Name (if different from driver)

  • Relationship to Child

  • Expectant Mom?

Waiver of Liability

  • 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 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.

    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.

  • Type Name

  • Participant Signature

Safety Check

Vehicle Information

  • Make

  • Model

  • Year

  • Airbags

Occupants

  • Number of Occupants

  • More than 7?

  • Number of Occupants

Location of Occupants on Arrival

  • Passenger

  • Type of Passenger

  • Driver-Middle

  • Type of Passenger

  • Passenger-Middle

  • Type of Passenger

  • Driver-Rear

  • Type of Passenger

  • Passenger-Rear

  • Type of Passenger

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

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

  • Child
  • 23 months or younger?

  • Age

  • 2 years or older?

  • Age

  • CRD?

  • Purchase OPRC Seat

  • Select the Seat Purchased.

  • Purchase Non-OPRC Seat

  • Manufacturer

  • Model

  • Rental of Special Needs Restraint

  • Manufacturer

  • Model

  • Date of Manufacture

  • Model #

  • Special Needs ID

  • WIC or Medicaid #

  • History Known?

  • Parent chooses to purchase seat?

  • Parent chooses to install seat as is.

  • Parent leaves with no install.

  • Is the parent the original owner of the CRD?

  • Installed Using:

  • CRD Type

  • CRD Manufacturer

  • Other (if not listed)

  • Model Name

  • Date of Manufacture

  • Model Number

  • History Known?

  • Caregiver/Parent advised by tech to replace seat?

  • Parent chooses to purchase seat

  • Parent chooses to install seat as is.

  • Parent leaves with no install.

Recall/Expired CRD

  • CRD past the expiration date

  • Was the parent/caregiver notified?

  • CRD is on recall list

  • Was the parent/caregiver notified?

Findings

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

  • 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

  • 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

  • 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:

  • 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?

  • 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:

Completion

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

  • Donation Given ($)

  • Technician Signature

  • Senior Checker (printed name, if applicable)

  • Senior Checker Signature (if applicable)

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