Highchair Quarterly Checklist

• Site conducted

  Select

• Date & Time Conducted

High Chair

• Highchair #

• Photo

  Media

• Does the chair have a footrest?

  Yes

  No

  N/A

• Is the fabric part of the chair removable and washable?

  Yes

  No

  N/A

• What are the conditions of the strap

  Good

  Fair

  Poor

  N/A

• What is the condition of the high chair?

  Good

  Fair

  Poor

  N/A

• Does the highchair need to be repaired

  Yes

  No

  N/A

• Does the high chair need to be replaced

  Yes

  No

  N/A

Completion

• Date & Time completed

  Date

• Name & Signature

  Sign