Information
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Audit Title
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Document No.
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Conducted on
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Location
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Technician Name
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Email Address
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Instructor Supplier
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Additional Personnel
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County
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Agency
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Technician Number
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Phone Number
Participant Information
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Driver Name
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Phone Number
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Email Address
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Relationship to Child
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Expectant Mom?
Waiver of Liability
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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.
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Participant Signature
Safety Check
Vehicle Information
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Make
- 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
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Model
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Year
- 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
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Airbags
- Front Driver
- Front Passenger
- Side
- Curtain
- None
- On/Off Switch Engaged
Occupants
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Number of children in seatbelts
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Number of adults in seatbelts
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Number of CRDs in vehicle
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Number of CRDs involved in crashes
Location of Occupants on Arrival
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Adults
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Teens
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Children
On Arrival (Inspection of child/seat - complete as found)
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Child 1
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Child Present
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Age
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Weight (lbs.)
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Height (inches)
CRD
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CRD?
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Is the parent the original owner of the CRD?
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Installed Using:
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CRD Type
- 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
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CRD Manufacturer
- 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)
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Model Name
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Date of Manufacture
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Model Number
Recall/Expired CRD
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Is the CRD past the expiration date?
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Was the parent/caregiver notified?
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Is the CRD on Recall List?
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Was the parent/caregiver notified?
Findings
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Selection (Height, weight, Manufacturer's Instructions/Labels, Special Health Care Needs):
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Child is within Manufacturer’s recommended height and weight ranges.
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Manufacturer’s instructions are present.
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Manufacturer’s labels are present and readable.
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The CRD is in good condition and working order with all parts present.
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Is this a Special Healthcare Needs CRD?
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Reason for Use?
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Child Placement
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If present, is the Carrier Handle in the correct position for travel?
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Are Add-ons present?
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Seat: Is the child placed correctly in the CRD?
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Gaps or spaces behind child
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CRD too large/small for child
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CRD inappropriate for child
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Harness: Is the harness threaded correctly according to child’s height, weight and direction?
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Harness threaded incorrectly or twisted
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Wrong slots for the child
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Harness is loose on child
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Retainer Clip: Is the Retainer Clip used correctly?
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Missing
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Threaded incorrectly
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Not at armpit level
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Broken
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Wrong Retainer clip for CRD
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Is the Harness snug on the child – passes the 1” test?
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Seat Installation (Location, Direction, Seatbelt, LATCH, Tether, Add-ons)
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Location: Is seat secured in appropriate location in the vehicle?
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In front of airbag
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Not enough space at that location in the vehicle
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Direction: Is seat facing the correct direction?
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Rear-facing too long (past manufacturer’s recommendations or child has outgrown the CRD)
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Forward facing too soon
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Side facing (jump seat)
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Is seat angle correct for child according to Manufacturer’s directions?
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Too much recline
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Too little recline
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Upright when recline is needed
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CRD Installed using:
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Seatbelt is in the locked mode.
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Locking Latchplate
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Switched Mode
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Locking Clip
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Seatbelt is routed correctly on the CRD.
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D-ring is present on shoulder belt and is in the lowest position for installation.
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CRD is secured to the vehicle and meets the "1" test.
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Is LATCH used correctly?
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Attached to incorrect anchor points
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Attached upside-down
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Not secured, does not meet "1" test
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Use seatbelt and LATCH together when not allowed by manufacturers
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Is Tether used correctly?
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Present but not used
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Incorrect anchor points used
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Attachment upside-down on anchor point – see LATCH manual
Departure
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All corrections were made.
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CRD was Purchased/Replaced
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Amount Collected
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Was this a new install (no previous seat being used in the vehicle for this child)?
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Was the parent able to properly install the CRD?
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Was the CRD placed in another location in the vehicle?
