Title Page
-
Document No.
-
Car seat inspection
-
Client / Site
-
Conducted on
-
Prepared by
-
Location
-
Personnel
-
Liability waiver
I understand that at all times the child restraint must be used in accordance with the instructions provided by the manufacturer of the child restraint and the instructions provided by the vehicle manufacturer. I understand that if I do not use the child restraint as stated in the manufacturer' instructions, the child restraint may not be effective in a crash. By signing below, I indicate that I have read this form, understand it, and agree to accept any and all responsibility for any misuse of the child restraint device or any installation contrary to the manufacturer's instructions. I also agree to release Melissa Wilder, nationally certified Child Passenger Safety Technician, from any present or future liability for any injuries or damages that may result from a vehicle collision.
I will participate in this car seat safety check and installed my child's child restraint.
I will also harness my child in the child restrain upon departure. -
Name:
-
Date:
-
Vehicle make/model/year:
Child's information
-
Child present?
- yes
- no
- unborn
-
Child's name
-
Child's age:
-
Child's height:
-
Child's weight:
-
Seat checked before
Obsevation upon arrival
-
Restraint location in vehicle
- Driver
- Passenger
- 2nd row driver
- 2nd row center
- 2nd row passenger
- 3rd row driver
- 3rd row center
- 3rd row passenger
- other
- uninstalled
-
Restraint installed
- No restraint
- Unistalled
- Seatbelt
- Lower anchors
- Tether
- Integrated seat
-
Restraint type
- RFO w/ base
- RFO w/o base
- Convertible RF
- Convertible FF
- Combination seat w/ harness
- Combination seat w/o harness
- HBB
- LBB
- Lap/shoulder seatbelt
- Lap only seat belt
- Car bed
- Vest
- Not retrained
-
Restraint manufacturer
- Baby Trend
- Britax
- Chicco
- Clek
- Combi
- Diono
- Dorel
- Evenflo
- Graco
- Harmony
- Orbit
- Peg Perego
- Recaro
- Other
-
Make and model number
-
Manufacture date:
-
Car seat history known
-
Restraint involved in a crash<br>
-
Labels missing
-
Restraint expired
-
Restraint recalled
-
Correct direction
-
Harness correct
-
Recline correct
-
Tether correct
-
Lower anchors
-
Seatbelt
Education
- RFO
-
Seatbelt
-
Lower Anchors
-
One inch or less movement
-
Angle
-
Height/weight minimums and maximums
-
RF until 2 or until the restraint is outgrown
-
Handle position on infant seat
-
Adjust harness height
-
Adjust fit/tightness
-
Chest clip
-
After market products and unregulated
-
Never leave child alone
-
Projectiles
-
Airbags
-
Unused seatbelt
-
Shopping carts
-
Car seats and safe sleep
-
Look before you lock
-
Lock unattended vehicles
Covertible seat
-
Seatbelt
-
Lower Anchors
-
Tether
-
One inch or less movement
-
Angle
-
Height/weight minimums and maximums
-
Adjust harness height
-
Adjust fit/tightness
-
Chest clip
-
Harness until age 5 or longer
-
After market products and unregulated
-
Look before you lock
-
Lock unattended vehicles
-
Projectiles
-
Airbags
Combination seat -
RF until 2 or until the restraint is outgrown
-
Height/weight minimums and maximums
-
After market products and unregulated
-
Seatbelt
-
Lower Anchors
-
One inch or less movement
-
Adjust harness height
-
Angle if indicated
-
Adjust fit/tightness
-
Harness until age 5 or longer
-
Chest clip
-
Look before you lock
-
Lock unattended vehicles
-
Projectiles
-
Airbags
Booster -
Height/weight minimums and maximums
-
Booster until able to 5 step
-
Seatbelt
-
Lower Anchors
-
After market products and unregulated
-
Lock unattended vehicles
-
Look before you lock
-
Projectiles
-
Airbags
-
Harness until age 5 or longer
Departure
-
Restraint location in vehicle
- Driver
- Passenger
- 2nd row driver
- 2nd row center
- 2nd row passenger
- 3rd row driver
- 3rd row center
- 3rd row passenger
- other
- uninstalled
-
Restraint location in vehicle
