Car Seat Appointment Request Form

Car Seat Appointment Request Form

Yuba County Health and Human Services- Car Seat Program
Thank you for requesting a car seat appointment. Please read the following carefully, fill out the information requested, sign the release form, and submit. A copy of the form will be sent to your email and a Certified Passenger Safety Technician (CPST) will reach out to you in order to schedule your appointment.

What you should know about this appointment:

A car seat appointment is an educational interaction between a child’s caregiver(s) and a certified child passenger safety technician (CPST) to promote the safety of the child while riding in a vehicle. This form gathers important information from caregivers that a CPST can use to prepare for a successful appointment. While it is generally preferable to conduct checkups in person, a virtual checkup can provide essential education when it is difficult to arrange in-person interactions, including during inclement weather or when social distancing is imperative. Be advised that you are not guaranteed a free car seat by attending this appointment, but a technician may recommend seat distribution/replacement based on eligibility and observed needs during this interaction.
Caregiver and Child Information
Caregiver Name*

First NameLast Name
Email
example@example.com
Phone Number*

Area CodePhone Number
My native language is...

English / ingles / lus AmesliskasSpanish/ españolHmong /Hmoob
I would prefer that written communications and forms be provided in:

English / ingles / lus AmesliskasSpanish / españolHmong/ Hmoob
Caregiver Date of Birth*

MonthDayYear
Date
Caregiver's relationship to the child
Is the caregiver present an expecting mom?(Y/N)
Child's Name

First NameLast Name
Child's Date of Birth (or expected date)*

MonthDayYear
Date
Child's Weight (if born)*
Child's Height (if born)*
Address

Dirección

Dirección de calle linea 2

CiudadEstado

Código postal
Please indicate any special needs relevant to car seat use:
Other Children, such as siblings, who regularly ride in the vehicle (age/weight):
Do you have a car seat you are using for your child?*
Car Seat Information

Please fill out the information below for the seat your child is currently using.Find the following information on a sticker on the car seat and/or it’s base. It is also located on the postcard that should be mailed in to register for recalls.
Car Seat BRAND
(ie: Baby Jogger, Baby Trend, Britax, Chicco, Clek, Combi, Cosco, Cybex, Diono, Evenflo, Graco, Harmony, Kids Embrace, Nuna, Peg Perego, Uppababy, Urbini, other)
Car Seat MODEL NAME
Example: Evenflo MAESTRO
Car Seat MODEL NUMBER
Car Seat MANUFACTURE DATE
Do you have a hard copy of the owner's manual? (Y/N)
Vehicle Information

Find the following information on registration documents, the vehicle owner’s manual, and/or on the sticker inside the driver-side door’s doorframe. You will need access to a vehicle for this appointment.
MAKE (i.e Ford, Toyota)*
MODEL (i.e Escape, Sienna)
MODEL STYLE (i.e. van, SUV,sedan, convertible)*
MODEL YEAR
Do you have a hard copy of the owner's manual? (Y/N)*
Please select ALL methods that would work for you.*

In Person Appointment
How did you hear about this program
Sign the Waiver of Liability
WHEREAS, I have voluntarily sought individual education concerning child safety seat installation conducted by Yuba County - Public Health Division and, WHEREAS, I have been informed and advised that the Yuba County-Public Health Division makes no express, or implied warranties as to the safety or fitness of any child safety seat; and WHEREAS, I have been informed and advised that in order for my child to be fully protected, I must secure my child in the child safety seat properly at all times, and at all times secure the safety seat properly in my vehicle according to the safety seat manufacturer's instruction which have been provided to me and according to the vehicle manual. NOW THEREFORE, in consideration of being provided with a child safety seat, I hereby agree:

1. That the County of Yuba, its officers, agents, employees and volunteers, and each of them shall not be responsible or liable for any injury, damage, loss or expense, either to me or my property incurred by my use of the afore-mentioned child safety seat.

2. I, my heirs, executors, administrators, and assigns hereby agree to defend and indemnify the County of Yuba, its officers, agents employees and volunteers, and each of them, against any and all manner of actions, causes of actions, suits, debts, claims, demands for damages or liability of expense of every kind and nature incurred or arising by reason of any actual or claimed negligent wrongful act or omission by me relating to the use of the afore-mentioned child safety seat.

I hereby represent that I can read, write, and understand the language in which this document is written and that I have carefully read and understand the contents of this document and that I am of 18 years of age or older.
Signature (Parent/Gaurdian/Caregiver Name) I agree with the terms outlined by the waiver above. And that the information I have provided on this form is correct

La Firma (Nombre del padre / tutor / cuidador) Estoy de acuerdo con los términos descritos en la exención anterior. Y que la información que he proporcionado en este formulario es correcta.
Sign/Firme*

Clear
Child Safety Seat Checklist Form

This form is for technicians to use as they inspect car seats that have been brought to an appointment or car seat check-up event.
Date of appointment/check

MonthDayYear
Date
Name of Technician

First NameLast Name
CPST Certification #

Vehicle Air Bag Checklist

	Yes	No
Driver's Side Air Bag
Passenger's Side Air Bag
Side Air Bag
Other Air Bag
Air Bag Disabled?
On/Off Switch?

Car Seat - Initial Assessment
Area/Location
Type of Restraint in use
Car Seat BRAND
Car Seat MODEL
Car Seat Manufacture Date

MonthDayYear
Date
Car Seat MODEL NUMBER
Car Seat Expiration Date (if not listed, estimate 6 years after manufacture date)

MonthDayYear
Date
Seat recalled? (Y/N)
Meets FMVSS 213? (Y/N)
Installed with or without child present?
Seat involved in a crash? (Y/N)
Seat History Known? (Y/N)
Vehicle tether ready? (Y/N)
Type of Retractor
Vehicle LATCH equipped? (Y/N)
Latch Plate Type
Rear Facing Infant Seat or Convertible Seat

RFO/CV Checklist

	Yes	No	N/A
Seat in a NON airbag position
Carrier handle in proper position
Seat at 45 degree reclined angle
Infant free of heavy bundling
Shoulder straps lie flat and are free from fraying or tears
Harness is snug
Retainer clip is present
Retainer clip is threaded correctly and at armpit level
Vehicle belt is routed properly through seat base
Vehicle belt secures seat tightly in vehicle
Seat belt locked properly (locking clip,switchable retractor, etc.)
Locking clip on correctly (or lock off on seat is used)
Crotch strap adjusted properly (if adjustable)
Buckle mechanism appears to open and lock properly
Seat free of added cushioning
Harness complete and attached correctly to the seat
Infant is within manufacturer's height/weight range of this seat
LATCH system used correctly

Forward-Facing Child Seat

FF Seat Checklist

	Yes	No	N/A
If airbag equipped, vehicle's seat is fully back in track
Seat in upright position
Child free of heavy clothing
Shoulder strap at or above shoulder
Straps lie flat and are free from fraying or tears
Harness is snug
Retainer clip is present
Retainer clip is threaded correctly and at armpit level
Vehicle belt is routed properly through the seat
Vehicle belt secures seat tightly in vehicle
Seat belt locked properly(locking clip,switchable retractor,etc)
Locking clip on correctly (or lock off on seat is used)
Crotch strap adjusted properly(if adjustable)
Buckle mechanism appears to open and lock properly
Seat free of added cushioning
Harness complete and attached correctly to the seat
Child is within manufacturer's height/weight range of this seat
LATCH system used correctly
Tether strap on and anchored correctly( if required)

Belt Positioning Booster Seat

BPB Checklist

	Yes	No	N/A
Lap/Shoulder belt fits child properly
Child had head protection
Child is within manufacturer's height/weight range of this seat

Vehicle Seat Belt

Vehicle Seat Belt Checklist

	Yes	No	N/A
Shoulder belt correctly positioned
Lap belt correctly positioned
Child securely restrained
Child fits the vehicle seat

OTHER Restraint
What restraint was brought in?

Other Restraint Checklist

	Yes	No	N/A
Restraint used according to manufacturer's instructions
Child is within manufacturer's height/weight range of this seat

Critical Misuses

Check all critical misuses you came across today.

	Check all that apply
Age and weight appropriateness of child passenger restraint system (CPRS)
Direction of CPRS
Placement of CPRS
Installation and secureness of CPRS to the vehicle seat (tight seat belt)
Secureness/tighness of harness straps and crotch strap of CPRS
Use of locking clip for certain vehicle seat belts
Fit of vehicle seat belt across child in BPB seat
Defective or broken CPRS
CPRS Expired

Corrective Actions Taken
Was a new seat distributed?
Car seat brand/model name for replacement seat
ex) Evenflo Maestro,
Model # for replacement seat
What type of seat was distributed
What was the funding source for this seat?

OTSAAACar Seat TrustRealignmentCDPH
The CPST took the following actions today

All corrections made were explained to the caregiver so that they could duplicate proper techniques on their ownDiscussed turn-around time and graduation timeInformed caregivers of any recallsInformation given on airbags, after market products, Kaitlyn's Law and other safety issuesCaregiver was the last to touch the seat, and installed it properly upon depatureDistributed grip liner to caregiverDistributed locking clip to caregiverDistributed pool noodle to caregiver
Enter any additional notes here:
Have you ever had an in-person car seat inspection before?

YesNo
Would you reccomend a virtual car seat appointment to a friend?

YesNo
What did you like about a virtual car seat inspections?
How could we improve a virtual car seat inspection for others?
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Car Seat Appointment Request Form

Caregiver and Child Information

Car Seat Information

Vehicle Information

Sign the Waiver of Liability

Child Safety Seat Checklist Form

Car Seat - Initial Assessment

Rear Facing Infant Seat or Convertible Seat

Forward-Facing Child Seat

Belt Positioning Booster Seat

Vehicle Seat Belt

OTHER Restraint

Critical Misuses

Corrective Actions Taken