Audit
Participant Information:
Time/date
Driver's name
Driver's address
Phone number
E-mail
Relationship to Child
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; 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 by 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 or 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.
Participant Signature
Vehicle Information
Vehicle year
Vehicle make and model
How many children in seatbelts?
How many child safety seats in the vehicle?
How many adults in seatbelts?
Do the Adults Wear Seatbelts?
Have any of the car seats been involved in a crash?
Airbags
Inspection Seat/Child (COMPLETE AS SEAT WAS FOUND)
Child 1
Child seat checked before?
Child Present?
Child's First Name
Child's Age
Child's Weight (lbs)
Child's Height (Inches)
Child's Date of Birth.
On Arrival.
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2.) CSS Installed Using (Select All That Apply)
No CSS (Mark- Go to #18
Uninstalled
Seatbelt
Tether
Lower Anchors
Integrated Seat (Mark - Go To #7)
3.) CRS Type
Picture of Seat as it was found
4.) Manufacturer:
Model Name:
5.) Model Number:
6.) Manufacture Date: mm/dd/yyyy
FINDINGS
7.) CSS History Known?
8.) CSS Involved in a Crash
9.) CSS Labels Missing
10.) CSS Recalled?
RECALL List checked?
NHTSA Recall List: http://www-odi.nhtsa.dot.gov/cars/problems/recalls/childseat.cfm
http://www-odi.nhtsa.dot.gov/cars/problems/recalls/childseat.cfm
11.) CSS on Recall List?
Participant Notified?
Problem corrected?
12.) Is seat facing correct direction?
13.) Is harness in correct harness slots?
If harnessed CSS, is it tightly installed? (1" test)
Are harness straps snug?
Is harness retainer clip at armpit level?
Is harness free of tears or twists?
14.) Is seat installed at the correct angle?
15.) Is LATCH correctly used?
16.) Is tether correctly used?
17.) Seatbelt Correct?
Is safety belt in locked mode? (Locking clip, switched retractor or locking latch plate).
Is locking clip used correctly?
Is safety belt routed correctly? (Belt Path)
Is Child within Manufacturer's Recommended height and weight range(s)?
Is child seated in appropriate location in vehicle?
If present, is carrier handle in correct position for travel?
ON DEPARTURE
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19.) CSS Installed Using (select all that apply)
20.) Coalition Provided a New CSS
21.) Restraint Type?
22.) CSS Manufacturer
Manufacture Date
23.) Model Number
25.) All Corrections Made?
26.) CSS/Vehicle Compatible
27.) Education Materials Given
Picture of Seat #1 upon completion of inspection
Child 2
Child Present?
Child seat checked before?
Child's First Name
Child's Age
Child's Weight (lbs)
Child's Height (Inches)
Child's Date of Birth.
On Arrival.
2.) CSS Installed Using (Select All That Apply)
annotation!!!
No CSS (Mark- Go to #18
Uninstalled
Seatbelt
Tether
Lower Anchors
Integrated Seat (Mark - Go To #7)
3.) CRS Type
Picture of Seat as it was found
4.) Manufacturer:
Model Name:
5.) Model Number:
6.) Manufacture Date: mm/dd/yyyy
FINDINGS
7.) CSS History Known?
8.) CSS Involved in a Crash
9.) CSS Labels Missing
10.) CSS Expired?
RECALL List checked?
NHTSA Recall List: http://www-odi.nhtsa.dot.gov/cars/problems/recalls/childseat.cfm
http://www-odi.nhtsa.dot.gov/cars/problems/recalls/childseat.cfm
11.) CSS on Recall List?
Participant Notified?
Problem corrected?
12.) Is seat facing correct direction?
13.) Is harness in correct harness slots?
If harnessed CSS, is it tightly installed? (1" test)
Are harness straps snug?
Is harness retainer clip at armpit level?
Is harness free of tears or twists?
14.) Is seat installed at the correct angle?
15.) Is LATCH correctly used?
16.) Is tether correctly used?
17.) Seatbelt Correct?
Is safety belt in locked mode? (Locking clip, switched retractor or locking latch plate).
Is locking clip used correctly?
Is safety belt routed correctly? (Belt Path)
Is Child within Manufacturer's Recommended height and weight range(s)?
Is child seated in appropriate location in vehicle?
If present, is carrier handle in correct position for travel?
ON DEPARTURE
annotation!!!
19.) CSS Installed Using (select all that apply)
20.) Coalition Provided a New CSS
21.) Restraint Type?
22.) CSS Manufacturer
23.) Model Number
Manufacture Date
25.) All Corrections Made?
26.) CSS/Vehicle Compatible
27.) Education Materials Given
Picture of Seat #1 upon completion of inspection
Child 3
Child Present?
Child seat checked before?
Child's First Name
Child's Age
Child's Weight (lbs)
Child's Height (Inches)
Child's Date of Birth.
On Arrival.
2.) CSS Installed Using (Select All That Apply)
annotation!!!
No CSS (Mark- Go to #18
Uninstalled
Seatbelt
Tether
Lower Anchors
Integrated Seat (Mark - Go To #7)
3.) CRS Type
Picture of Seat as it was found
4.) Manufacturer:
Model Name:
5.) Model Number:
6.) Manufacture Date: mm/dd/yyyy
FINDINGS
7.) CSS History Known?
8.) CSS Involved in a Crash
9.) CSS Labels Missing
10.) CSS Expired?
RECALL List checked?
NHTSA Recall List: http://www-odi.nhtsa.dot.gov/cars/problems/recalls/childseat.cfm
http://www-odi.nhtsa.dot.gov/cars/problems/recalls/childseat.cfm
11.) CSS on Recall List?
Participant Notified?
Problem corrected?
12.) Is seat facing correct direction?
13.) Is harness in correct harness slots?
If harnessed CSS, is it tightly installed? (1" test)
Are harness straps snug?
Is harness retainer clip at armpit level?
Is harness free of tears or twists?
14.) Is seat installed at the correct angle?
15.) Is LATCH correctly used?
16.) Is tether correctly used?
17.) Seatbelt Correct?
Is safety belt in locked mode? (Locking clip, switched retractor or locking latch plate).
Is locking clip used correctly?
Is safety belt routed correctly? (Belt Path)
Is Child within Manufacturer's Recommended height and weight range(s)?
Is child seated in appropriate location in vehicle?
If present, is carrier handle in correct position for travel?
ON DEPARTURE
annotation!!!
19.) CSS Installed Using (select all that apply)
20.) Coalition Provided a New CSS
21.) Restraint Type?
22.) CSS Manufacturer
23.) Model Number
Manufacture Date
25.) All Corrections Made?
26.) CSS/Vehicle Compatible
27.) Education Materials Given
Picture of Seat #1 upon completion of inspection
Technician Discussed: (Select all that apply)
28.) Airbags
29.) Unused Seatbelt
30.) Projectiles
31.) Unattended children in or around cars.
32.) Next steps
Caregiver Sign Off
33.) I harnessed child in CSS
34.) I participated/installed CSS today
Caregiver Initials
Comments
Replaced/Donated Seats
Was CRS Replaced or donated for child #1?
If replaced, what type?
Manufacturer:
Model Name:
Model Number:
Manufacture Date: mm/dd/yyyy
Was CRS Replaced or donated for child #2?
If replaced, what type?
Manufacturer:
Model Name:
Model Number:
Manufacture Date: mm/dd/yyyy
Was CRS Replaced or donated for child #3?
If replaced, what type?
Manufacturer:
Model Name:
Model Number:
Manufacture Date: mm/dd/yyyy
Was CRS Replaced or donated for child #4?
If replaced, what type?
Manufacturer:
Model Name:
Model Number:
Manufacture Date: mm/dd/yyyy
Follow-Up
Were ALL Misuses corrected?
Parent was able to properly install car seats?
Comments
Technician Signature
Parent Signature
CPS Technician information:
Technician name:
Technician certification number:
Technician phone number:
Technician e-mail:
