Car Seat Checkup Form

Please check for answers on our Web site before filling out this form. Answers to most questions will be found by clicking on the following links at the top of our home page: FAQs, Recalls, Technical, and Boosters.

We will get back to you as soon as possible. SafetyBeltSafe U.S.A. welcomes your questions, but we may be unable to reach you due to an incorrect email address or other technical error. If our response is delayed more than two weeks, please send your question again. Thank you.

First Name
Last Name
Organization
Occupation
Street Address
City
State
Zip Code
Country	U.S. Other
Home Phone
Work Phone
Email address (required)
What is your role with this child?
Number of adults in your vehicle
Number of children under 12 in your vehicle
Vehicle #1: make
Vehicle #1: model
Vehicle #1: year
Vehicle #1: Passenger air bag (right front)?	Yes No
Vehicle #1: Air bag on-off switch?	Yes No
Vehicle #1: Side air bags in back seat?	Yes No Don't know
Vehicle #2: make
Vehicle #2: model
Vehicle #2: year
Vehicle #2: Passenger air bag (right front)?	Yes No
Vehicle #2: Air bag on-off switch?	Yes No
Vehicle #2: Side air bags in back seat?	Yes No Don't know

Section B:
Information about your child and your car seat (fill out a separate section of this form for each child)

**Child 1**
Age of child
Weight of child
Medical or behavioral concerns?
Which way is the child facing in the car?	Forward Rearward
Where in the car is the child riding?	Front seat Back seat 3rd seat (van) Driver side Passenger side Center
Manufacturer of car seat
Model name
Model number (see sticker on seat)
Mfr. date (see sticker on seat)	Month: Day: Year:
How is the car seat attached to the car?	Lap belt only Lap and shoulder belt LATCH hardware
Does the car seat have a top tether strap?	Yes No
If yes, is the tether strap attached to the car?	Yes No
Are you using a locking clip?	Yes No
Was the seat new when you got it?	Yes No
If no, explain
Are you aware of any recalls?	Yes No
If yes, describe the recall(s) and what has been done?
Your questions or problems:

**Child 2**
Age of child
Weight of child
Medical or behavioral concerns?
Which way is the child facing in the car?	Forward Rearward
Where in the car is the child riding?	Front seat Back seat 3rd seat (van) Driver side Passenger side Center
Manufacturer of car seat
Model name
Model number (see sticker on seat)
Mfr. date (see sticker on seat)	Month: Day: Year:
How is the car seat attached to the car?	Lap belt only Lap and shoulder belt LATCH hardware
Does the car seat have a top tether strap?	Yes No
If yes, is the tether strap attached to the car?	Yes No
Are you using a locking clip?	Yes No
Was the seat new when you got it?	Yes No
If no, explain
Are you aware of any recalls?	Yes No
If yes, describe the recall(s) and what has been done?
Your questions or problems:

**Child 3**
Age of child
Weight of child
Medical or behavioral concerns?
Which way is the child facing in the car?	Forward Rearward
Where in the car is the child riding?	Front seat Back seat 3rd seat (van) Driver side Passenger side Center
Manufacturer of car seat
Model name
Model number (see sticker on seat)
Mfr. date (see sticker on seat)	Month: Day: Year:
How is the car seat attached to the car?	Lap belt only Lap and shoulder belt LATCH hardware
Does the car seat have a top tether strap?	Yes No
If yes, is the tether strap attached to the car?	Yes No
Are you using a locking clip?	Yes No
Was the seat new when you got it?	Yes No
If no, explain
Are you aware of any recalls?	Yes No
If yes, describe the recall(s) and what has been done?
Your questions or problems:

**Child 4**
Age of child
Weight of child
Medical or behavioral concerns?
Which way is the child facing in the car?	Forward Rearward
Where in the car is the child riding?	Front seat Back seat 3rd seat (van) Driver side Passenger side Center
Manufacturer of car seat
Model name
Model number (see sticker on seat)
Mfr. date (see sticker on seat)	Month: Day: Year:
How is the car seat attached to the car?	Lap belt only Lap and shoulder belt LATCH hardware
Does the car seat have a top tether strap?	Yes No
If yes, is the tether strap attached to the car?	Yes No
Are you using a locking clip?	Yes No
Was the seat new when you got it?	Yes No
If no, explain
Are you aware of any recalls?	Yes No
If yes, describe the recall(s) and what has been done?
Your questions or problems:

SafetyBeltSafe U.S.A. • P.O. Box 553, Altadena, CA 91003