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2. Inspector
   -- Select One --Dirk- #T754956Ellis- #754955
3. Inspection Date
   Inspection Date
4. Child present?
   -- Select One --yesno
5. Expectant parent or grandparent?
   -- Select One --yesno
7. Parent Information
9. Name
10. Email Address
12. Address
14. City
15. State
16. Zip Code
18. Phone Number
20. Child Information
22. Name
23. Age
25. Approximate weight (lbs)
26. Approximate Height (feet and inches)
28. Parent Release of Liability

    I understand that the sole purpose of this program is to reduce the incident of improper installation and use of child safety seats; this inspection is provided free of charge in the interest of public safety; this program cannot fully evaluate the quality, safety, condition of the child safety seat, or any component of my vehicle including the seats, safety belts, and airbag systems; and that 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 in 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 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 form liability and responsibility for any and all damage(s) caused to my vehicle and/or contents therein while installing the child safety seats.

     

30. Electronic Signature*

    By typing my name here I agree and consent to the Parent Release of Liability statement above.

32. Seat information
34. Manufacturer
    -- Select One --Baby TrendBritaxChiccoCombi USADionoDorelEvenfloFORBGracoKiddyMerrittRecaro
35. Model
37. Number
38. Manufacture OR Expiration Date
40. Seat Type
    -- Select One --Harnessed Rear FacingHarnessed Forward FacingBoosterChild with Adult Seat BeltUnrestrained Child
41. Arrived Uninstalled?
    -- Select One --YesNo
43. How the seat Arrived

45. To check for recalls visit https://www-odi.nhtsa.dot.gov/recalls/childseat.cfm 

47. Recalled or expired?
    -- Select One --yesno
48. Incorrect seat for child (MFG guidelines)
    -- Select One --yes (incorrect seat)no (correct seat)
50. Incorrect harness type for child
    -- Select One --yes (incorrect harness type)no (correct harness type)
51. Installation
    -- Select One --arrived installedarrived uninstalled
53. CSS History
    -- Select One --History known- no issuesHistory unknownSeat has been in a crash
54. Participant was notified of any issues in this section

    1. yes
    2. no
56. Checking for Errors

    Indicate errors found 

58. Child seat in correct location in vehicle

    1. yes

    1. no (and corrected)

    1. no (unable to correct)

    1. n/a
60. Carrier handle in correct travel position

    1. yes

    1. no (and corrected)

    1. no (unable to correct)

    1. n/a
62. Seat is facing correct direction?

    1. yes

    1. no (and corrected)

    1. no (unable to correct)

    1. n/a
64. Seat installed at correct angle?

    1. yes

    1. no (and corrected)

    1. no (unable to correct)

    1. n/a
66. Seat tightly installed?

    1. yes

    1. no (and corrected)

    1. no (unable to correct)

    1. n/a
68. Safety belt in locking mode?

    1. yes

    1. no (and corrected)

    1. no (and unable to correct)

    1. n/a
70. Locking clip used correctly?

    1. yes

    1. no (and corrected)

    1. no (unable to correct)

    1. n/a
72. Safety belt routed correctly?

    1. yes

    1. no (and corrected)

    1. no (unable to correct)

    1. n/a
74. Tether used correctly?

    1. yes

    1. no (and corrected)

    1. no (unable to correct)

    1. n/a
76. LATCH used correctly?

    1. yes

    1. no (and corrected)

    1. no (unable to correct)

    1. n/a
78. Harness in correct slots?

    1. yes

    1. no (and corrected)

    1. no (unable to correct)

    1. n/a
80. Harness snug/ education provided?

    1. yes

    1. no (and corrected)

    1. no (unable to correct0

    1. n/a
82. Harness retainer clip at armpit level/ education given

    1. yes

    1. no (and corrected)

    1. no (unable to correct)

    1. n/a
84. Harness Free of tear or twists/ education given

    1. yes

    1. no (and corrected)

    1. no (unable to correct)

    1. n/a
86. Additional Education Provided
88. 1. Kids in hot/cold cars
    2. Carriers are not bassinets
    3. Carriers in shopping carts
    4. How jackets affect harness fit
Leave This Blank:


90. 1. Receive an email copy of this form.
91. Email address

    This field is not part of the form submission.

92. Submit

* indicates a required field