Fillable Car Seat Check Form v.4.7 (Colorado Department of Transportation)

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Car Seat Check Form v.4.7 (Colorado Department of Transportation)

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The Car Seat Check Form v.4.7 (Colorado Department of Transportation) form is 2 pages long and contains:

  • 1 signature
  • 21 check-boxes
  • 222 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Colorado Department of Transportation

BROWSE COLORADO DEPARTMENT OF TRANSPORTATION (CO) FORMS

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First Name
Vehicle Make/Mfg. (e.g. Chevy, Buick)
Caregiver Signature
Child present
1. Child/CS Location in Vehicle
2. Child/CS Installed Using
(select all that apply)
D
Child’s age
Height/inches Weight/pounds
0<1
3<4
6<7
1<2
4<5
8<9
2<3
front row Other seat location
Explain:
back
3rd row
5<6
9+
Yes
Yes
No
No
Unborn
NCS
Month Day Year
Today’s Date
Vehicle Model (e.g. Malibu, Enclave) Vehicle Year
Street Address
City
Phone Email Address
State Zip
Last Name
Car Seat Check Form v.4.7
CHILD ___
ON ARRIVAL
/ /
/ /
/ /
No CS
Uninstalled
Tether
Integrated Seat
Lower Anchor
Unrestrained
Other:
3. Restraint Type:
5. CS MFG:
6. Model Name:
7. Model Number:
8. MFG Date (MM/DD/YYYY):
9. Expiration Date (MM/YYYY):
10. CS Expired?
RF Only without Base
RF Only with Base
Base Only
RF Convertible
FF with Harness
Belt Positioning Booster
Lap/Shoulder Seat Belt (go to #21)
Lap Only Seat Belt (go to #21)
Vest
Other:
Seat Belt
Yes No
4. CS Labels Missing?
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 belt and airbag systems; this program cannot guarantee my child’s safety in a crash. I understand that to have full protective benet 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, and in conformance with Colorado law. 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.
What CPS Agency is hosting this event? Technicians Participating (T# and last name, include Primary)
CS = Car Seat | RF = Rear-Facing | FF = Forward-Facing | NCS = No Child Seat on Arrival
Adaptive Booster
Large Medical Seat
Specialized Restraint
What state is this event taking place in?
N/A
Online Form ID
County
Unknown
11. CS Recalled
Yes No
Unknown
NCS
Event
click to sign
signature
click to edit
N/A N/A
FINDINGS ON ARRIVAL
ON DEPARTURE
Yes No Yes No
19. Lower Anchors Correct
20. Tether Correct
Yes
Yes
Not Used
Too Loose
Routing
Not Appropriate Tether
Attachment (i.e. cargo tie down)
Connector Orientation (i.e. upside
down)
Twisted
Exceeds Weight Limit
Other:
***If no: check all that apply
No
No
NCS
NCS
21. Seat Belt Correct
22. Handle Position Correct
24. Is the load leg installed correctly
per manufacturer’s instructions?
Yes
Yes
Yes
Yes
Too Loose
Retractor Not Locked
Locking Clip
Routing (i.e. around crotch buckle/
harness/belt path)
Used with Lower Anchor
Child Fit (i.e. booster belt t, behind the
back, under the arm)
Other:
23. Are there non-regulated products?
***If no: Check all that apply
No
No
No
No
NCS
NCS
NCS
N/A
12. CS History Known
13. CS Involved in a Crash
14. CS Secured Per MFG’s Instructions
16. CS Correct Direction Per State’s Law
17. CS Harness Correct
Yes
Yes
Yes
Yes
Yes
Twisted
Too Loose
Retainer Clip: Wrong Placement
Harness Slot: Wrong Placement
Crotch Buckle: Location/Routing
Harness Altered in Some Way
Other:
Harness not used
Damaged
***If no: check all that apply
No
No
No
No
NCS
No
NCS
Unknown
41. I harnessed a child/doll in a CS 42. I participated in installing this CS today.
43. Caregiver’s initials
Yes
Yes, by
caregiver.
RF Only without Base
RF Only with Base
FF with Harness
Belt Positioning Booster
Lap/Shoulder Seat Belt
Lap Only Seat Belt
Adaptive Booster
Vest
RF Convertible
Base Only
No
Yes, by
technician.
28. Was previous seat discarded?
29. Was previous seat recycled?
30. Restraint type:
Other:
Documentation Box:
CAREGIVER SIGN OFF
25. Child/CS location in vehicle
***If no: CS Donor
26. Child/CS Installed Using
(select all that apply)
D
front row
Other seat location
back
3rd row
No CS
Uninstalled
Tether
Integrated Seat
Lower Anchor
Unrestrained
Other:
Seat Belt
Explain:
Yes
TECHNICIAN DISCUSSED:
airbags • unused seat belts • projectiles
expiration date • premature transition
next steps • best practice vs. state law
No
/ /
/ /
Yes No
31. CS MFG:
32. Model Name:
33. Model Number:
34. MFG Date (MM/DD/YYYY):
35. Expiration Date (MM/DD/YYYY):
40. Educational materials given?
27. Is this the same CS as ‘On Arrival’?
***If no: check all that apply
Incorrect Use of the Vehicle Anchors
Exceeds Weight Limit
Twisted
Routing (i.e. around crotch buckle/
harness/belt path)
Connector Orientation (i.e. upside
down)
Too Loose
Used with a Seat Belt
Other:
18. Recline Angle Correct
Yes No
NCS
Yes No
38. All corrections made prior to
departure?
Yes No
39. Is the CS compatible with the vehicle?
NCS
Demonstration Seat
NCS
Large Medical Seat
Specialized Restraint
15. CS Correct Direction Per
MFG’s Instructions
Yes No
NCS
NCS
No
Donation Amount
Yes No
37. Caregiver Donation
N/A
N/A
N/A
N/A
Meets Eligibility Requirements
N/A
N/A
N/A
N/A
N/A
Yes No
36. Is the CS registered?
NCS
44. Final Inspection
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Car Seat Check Form v.4.7 (Colorado Department of Transportation)

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Completed 13 August 2020

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