APPENDIX A
Site Visit Form
A- 1
Child Safety Seat Inspection Station Site Visit Form
Date visited:
Location Name:
Child Safety Seat Inspection Station Site Visit Form
Date visited:
Observation conducted by:
Inspection Station Location Name:
Street Address
City, State:
OPERATIONAL
CONTACT:
Where is the service provided?
Fixed Site
Mobile
Both
In what type of geographic setting is this inspection station located?
Urban
Suburban
Rural, Describe:
When did inspection station begin operating (month/year)?
How long has this inspection station been in continuous operation?
How many inspections are completed per MONTH?
Is a fee charged for this service?
Yes
No
If yes, please explain:
What, if any, special populations are targeted with more emphasis?
Low-Income
African American
Hispanic
Asian
Migrant Laborers
other
Are special marketing techniques, messages and/or materials used to reach these special
populations? Are languages other than English used?
If answer is yes to either or both questions, please explain:
What is the service delivery schedule? Which, if any, days/hours see more traffic?
Fixed site, set days/hours, drop-in basis. Explain:
Fixed site, set days/hours, by appointment only. Explain:
Fixed site, by appointment only. Explain:
Mobile site, set days/hours, drop-in basis. Explain:
Mobile site, set days/hours, by appointment only. Explain:
A- 2
Child Safety Seat Inspection Station Site Visit Form
Date visited:
Location Name:
Does the station have access to a trailer/van or other accommodation for mobile inspection
services?
Source:
Explain:
Does the station participate in community inspection “clinic” events? Explain:
What tools/equipment are stocked?
Up-to-date Recall List
CSS Manufacturer's Instructions
Locking Clips
Belt-shortening Clips
Replacement Seats
Foam Noodles
Slip guard
Other
How are Customers/Participants Educated?
Participants are instructed and have hands-on involvement with seat installation
Participants observe the inspectors and may assist with seat installation
Participants receive written materials
Participants receive a telephone number to call for follow-up information/questions
Inspectors ask and educate about the use of restraint systems in other vehicles
Inspectors ask and educate about other family members (age, etc.)- if use safety belts and/or
booster seats
Inspectors mention and/or provide material specifically about the reasons and risks of using safety
belts alone, the reasoning/benefits of booster seats, not using seat restraints, etc.
Inspectors mention about changes in restraint systems that will be needed (as the child gets older
and bigger- preparing and educating parents for the future)
Inspectors provide information about state laws regarding child restraint and safety belt use
Other:
Explain details and describe educational materials used:
A- 3
Child Safety Seat Inspection Station Site Visit Form
Date visited:
Location Name:
Do inspectors involve children in the inspection? If so, how?
What "forms" are used?
Inspection form
Seat Replacement form
Liability waiver statement/agreement
Evaluation form
Other:
How is inspection data collected?
Standardized paper form
Computer software (e.g. Palm Pilot)
Both
Explain details:
How long is data kept?
How is inspection data compiled and stored?
How long is data kept?
Hand tallying and filed
Computer database (e.g., scanned, entered via keyboard, downloaded from Palm Pilot)
Both
Explain details:
What is the replacement seat policy?
Seats replaced free of charge
Explain details (when, why [e.g., recalled], how ):
Average total # seats provided per MONTH:
# infant seats provided per MON TH :
# convertible seats provided per MON TH :
# boos ter seats provided per MON TH :
A- 4
Child Safety Seat Inspection Station Site Visit Form
Date visited:
Location Name:
Seats replaced free of charge on a selective basis
(e.g. Medicaid eligible, etc.)
Explain details:
Average total # seats provided per MONTH:
# infant seats provided per MON TH :
# convertible seats provided per MON TH :
# boos ter seats provided per MON TH :
Seats replaced for a fee
Explain details:
Average total # seats provided per MONTH:
# infant seats provided per MON TH :
# convertible seats provided per MON TH :
# boos ter seats provided per MON TH :
Seats are loaned
Short term loans (up to 2 months)
Explain details and fees, if any:
Long term loans (for more than 2 months)
Explain details and fees, if any:
No seat replacement offered.
handled):
Average # seats provided per MONTH
# infant seats provided per MON TH :
# convertible seats provided per MON TH :
# boos ter seats provided per MON TH :
Average # seats provided per MONTH:
# infant seats provided per MON TH :
# convertible seats provided per MON TH :
# boos ter seats provided per MON TH :
Explain details (including how recalled seat that has not been fixed is
If program has a seat replacement policy:
How are replacement seats funded?
Funds for seats come from general program budget
Funds for seats come from separate funding source, explain:
Local community group/partner donates funds
Local community group/partner donates seats
National group/partner donates funds
National group/partner donates seats
Other – Explain:
A- 5
Child Safety Seat Inspection Station Site Visit Form
Date visited:
Location Name:
How do you acquire replacement seats?
Program purchases seats directly from manufacturer
Program purchases seats via buying group or other organization
Program receives seats from separate source, explain:
Individual receives seats through voucher or similar program
Explain:
Other – Explain:
How/Where are replacement seats stored?
Seats are shipped to station and stored on-site
Seats are stored off-site
In another building
Other – Explain:
In the building
In a trailer/van
In a trailer/van
In a storage unit
If program offers loaner seats, are seats put into program as:
NEW - PURCHASED by the program or DONATED (circle one or both as applicable)
Explain details:
How long are these seats used by program?
How are seats maintained?
USED/SECOND-HAND - PURCHASED by the program or DONATED
(circle one or both as applicable)
Explain details:
How long are these seats used by program?
How are seats maintained?
Do marketing messages mention about possible "free replacements or availability of seats"?
Explain why or why not and if yes, how:
A- 6
Child Safety Seat Inspection Station Site Visit Form
FREQUENT CSS MISUSE
List the 3 Misuses Encountered Most Frequently:
Safety belt NOT holding safety seat tightly
Locking clip used incorrectly or not used
when needed
Safety seat harness loose on child
Harness retainer clip in wrong position or
not present when required
Most common infant seat misuse:
Infant facing forward too early
Infant too tall for infant seat
Infant too heavy for infant seat
Infant too small for convertible seat
Date visited:
Location Name:
CONTACT:
Safety seat recalled, not fixed
Safety seat too old
Harness in wrong slots
Other, please specify:
Harness in wrong slots
Other, please specify
Most common convertible/FF seat with harness misuse:
Child too tall for convertible seat
Other, please specify
Child too heavy for convertible
seat/forward facing seat w/harness
Harness in wrong slots
Most common booster seat misuse:
Child too small/young for booster seat
Shoulder belt under arm/behind back of
child
Other, please specify:
Most common safety belt misuse:
Child too small/young for adult safety belt
Shoulder belt under arm/behind back of
child
Other, please specify:
A- 7
Child Safety Seat Inspection Station Site Visit Form
STAFFING
CONTACT:
Training Required:
Administrator
Paid Position?
Date visited:
Location Name:
Yes
No
Title:
# at this site:
Time:
Duties:
Training Required:
Scheduler
Paid Position?
Yes
No
Title:
# at this site:
Time:
Duties:
Senior Checker
Paid Position?
Yes
Training Required:
No
Title:
# at this site:
Time:
Duties:
Inspector
Paid Position?
# at this site:
Training Required:
Yes
No
Title:
Time:
Duties:
A- 8
Child Safety Seat Inspection Station Site Visit Form
Recorder/Scribe/Assistant
Paid Position?
Yes
Date visited:
Location Name:
Training Required:
No
Title:
# at this site:
Time:
Duties:
Other
Paid Position?
Training Required:
Yes
No
Title:
# at this site:
Time:
Duties:
Other
Paid Position?
Training Required:
Yes
No
# at this site:
Title:
Time:
Duties:
Do you use volunteers for inspection station services?
How do you recruit volunteers?
Do you have problems with scheduling/coordinating your volunteers? If so, what?
Do you have any problems with turnover of staff? If so, how do you deal with it? How do you
prevent it?
Do you regularly monitor “inspections”? If so, who monitors them and how often?
A- 9
Child Safety Seat Inspection Station Site Visit Form
Date visited:
Location Name:
How do you initially educate your staff?
Have you identified additional training needs for you and/or your staff?
If yes, what training needs have been identified and are the training resources in your area
adequate and convenient for you and your staff to meet those needs?
How do you educate/inform your staff about recalls, new information, announcements, etc.?
(Use bulletin board, memos, etc.)
PROMOTIONAL OUTREACH ACTIVITY
CONTACT:
Give-away items (e.g. buttons, coloring books)
Specify:
How/where distributed/displayed:
Were there indications you saw/heard that showed this activity had an impact? If yes, explain:
A - 10
Child Safety Seat Inspection Station Site Visit Form
Date visited:
Location Name:
Brochures/Flyers
Specify:
How/where distributed/displayed:
Were there indications you saw/heard that showed this activity had an impact? If yes, explain:
Posters
Specify:
How/where distributed/displayed:
Were there indications you saw/heard that showed this activity had an impact? If yes, explain:
Newspaper ads/PSAs/articles
Specify:
How/where distributed/displayed:
Were there indications you saw/heard that showed this activity had an impact? If yes, explain:
A - 11
Child Safety Seat Inspection Station Site Visit Form
Date visited:
Location Name:
Radio ads/PSAs/articles
Specify:
How/where distributed/displayed:
Were there indications you saw/heard that showed this activity had an impact? If yes, explain:
TV ads/PSAs/articles
Specify:
How/where distributed/displayed:
Were there indications you saw/heard that showed this activity had an impact? If yes, explain:
Community Events
Specify:
How/where distributed/displayed:
Were there indications you saw/heard that showed this activity had an impact? If yes, explain:
A - 12
Child Safety Seat Inspection Station Site Visit Form
Date visited:
Location Name:
Word of Mouth
Specify:
How/where distributed/displayed:
Were there indications you saw/heard that showed this activity had an impact? If yes, explain:
Other
Specify:
How/where distributed/displayed:
Were there indications you saw/heard that showed this activity had an impact? If yes, explain:
Do you provide any specific marketing, promotional activities, etc. to (check all that apply):
Health care providers in your community
How did you “tailor” the message to this group?
How frequently did you contact this group?
Were there indications you saw/heard that showed this activity had an impact? If yes, explain:
A - 13
Child Safety Seat Inspection Station Site Visit Form
Date visited:
Location Name:
Child care workers/Head Start staff
How did you “tailor” the message to this group?
How frequently did you contact this group?
Were there indications you saw/heard that showed this activity had an impact? If yes, explain:
School systems
How did you “tailor” the message to this group?
How frequently did you contact this group?
Were there indications you saw/heard that showed this activity had an impact? If yes, explain:
Faith-based communities
How did you “tailor” the message to this group?
How frequently did you contact this group?
Were there indications you saw/heard that showed this activity had an impact? If yes, explain:
A - 14
Child Safety Seat Inspection Station Site Visit Form
Date visited:
Location Name:
Parent groups
How did you “tailor” the message to this group?
How frequently did you contact this group?
Were there indications you saw/heard that showed this activity had an impact? If yes, explain:
Grandparent groups
How did you “tailor” the message to this group?
How frequently did you contact this group?
Were there indications you saw/heard that showed this activity had an impact? If yes, explain:
Other
How did you “tailor” the message to this group?
How frequently did you contact this group?
Were there indications you saw/heard that showed this activity had an impact? If yes, explain:
A - 15
Child Safety Seat Inspection Station Site Visit Form
Date visited:
Location Name:
Other
How did you “tailor” the message to this group?
How frequently did you contact this group?
Were there indications you saw/heard that showed this activity had an impact? If yes, explain:
Do you have any “specialized” types of promotion, inspection days and/or activities? If so,
what?
For example: Have you had any special promotions/activities with a focus on booster seat
inspections?
With respect to promoting the inspection station services, have there been relationships or
partnerships that have been particularly helpful? If so, please explain details and why they were
helpful? Are there any partnerships that you would like to have that you don't have now?
A - 16
Child Safety Seat Inspection Station Site Visit Form
Date visited:
Location Name:
FUNDING & BUDGET
CONTACT:
(Indicate anticipated terms of funding source including duration/consistency of funds, how often
applications must be made, etc.)
Private sources:
Grant-based
Explain:
Corporate Sponsorship
Explain:
Self-sustaining
Explain:
Other
Explain:
Public sources:
Grant-based
Explain:
Contract
Explain:
Combined
Explain:
A - 17
Child Safety Seat Inspection Station Site Visit Form
Date visited:
Location Name:
What is the annual budget for this inspection station?
Less than $5,000 per year
$5001 – $15,000 per year
$15,001 – $25,000 per year
$25,001 – $50,000 per year
$50,001 – $75,000 per year
More than $75,001
Indicate the expenses covered by this budget:
Salaries
Space
Tools/equipment
Replacement seats
Promotional Materials
Office Supplies
Overhead
Other:
What, if any, In-Kind services and/or materials are provided and from what sources?
How are inspectors paid for their services?
Volunteers
Salaried employees, Explain details/rate of pay:
Contract employees, Explain details/rate of pay:
Does the inspection station have liability insurance coverage?
Separate policy for site
Covered under another policy
No coverage
Are inspectors required to have individual liability coverage?
If yes, does the station pay for this coverage?
Yes
Yes
No
No
A - 18
Child Safety Seat Inspection Station Site Visit Form
Date visited:
Location Name:
DEVELOPMENT OF THE INSPECTION STATION
CONTACT:
What was the impetus for the development of this station? (Safe Kids Coalition, Hospital
Foundation/Education Service, Retail, Law Enforcement sponsored, State Highway Safety
Office?)
Who/what program/what resources were most helpful in the development of this station?
What challenge(s) was/were encountered in the initial development and setting up of this
inspection station?
Challenge
Solution
Has the availability of resources/funding changed since the initial operation of this inspection
station? If so, what were the implications and how were they handled? What resources would
you like to have that you don't have now?
A - 19
Child Safety Seat Inspection Station Site Visit Form
Date visited:
Location Name:
What challenge(s) was/were encountered in operating this inspection station or on-going
challenges?
Challenge
Solution
What, if any, significant changes were made to the inspection station since it began and why?
Administrative, explain:
Location, explain:
A - 20
Child Safety Seat Inspection Station Site Visit Form
Date visited:
Location Name:
Funding, explain:
Personnel structure, explain:
Are significant changes to the inspection station under consideration or imminent?
Administrative, explain:
Location, explain:
Funding, explain:
Personnel structure, explain:
What circumstances would cause the inspection station to terminate?
A - 21
Child Safety Seat Inspection Station Site Visit Form
Date visited:
Location Name:
EVALUATION
CONTACT:
Is this program evaluated?
Yes
No
What basis:
Quantity of Inspections
Length of Individual Inspections
Misuse Patterns
Frequency of Repeat Customers
Customer Satisfaction
Customer Follow-up (to determine if correct use lessons learned were retained)
Other:
By whom:
Station Staff
Outside Source, explain:
Other:
Tools Used (describe how used):
Inspection Forms
Customer Surveys
Customer Phone interviews
Follow-up Inspections
Anecdotal
Other:
Have there been changes to the evaluation process over time?
Are changes to the evaluation process anticipated?
A - 22
Child Safety Seat Inspection Station Site Visit Form
Date visited:
Location Name:
OTHER COMMENTS
CONTACT:
What are the most FREQUENT reasons people give you for using your service?
Have you identified reasons why more people in your target DO NOT utilize your service?
If you had the chance to start over again, is there anything you would do differently? If yes,
explain:
What would you recommend to other organizations starting an inspection station as the most
important things to do?
What would you recommend to other organizations starting an inspection station as the most
important things to avoid?
Do you have any other recommendations for organizations starting an inspection station?
Is there anything you wish we would have asked but didn't?
Any additional comments about this inspection station (unique features, special programming,
etc.):
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Child Safety Seat Inspection Station Site Visit Form
Date visited:
Location Name:
COMMENTS FROM ADMINISTRATORS/SPONSORS/STAFF/OTHERS
Name/Title:
Discussion:
Name/Title:
Discussion:
Name/Title:
Discussion:
Name/Title:
Discussion:
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Child Safety Seat Inspection Station Site Visit Form
Date visited:
Location Name:
Contact information
Name:
Title/Agency:
Address:
City/State/Zip:
Phone:
FAX:
Email:
Name:
Title/Agency:
Address:
City/State/Zip:
Phone:
FAX:
Email:
Name:
Title/Agency:
Address:
City/State/Zip:
Phone:
FAX:
Email:
Name:
Title/Agency:
Address:
City/State/Zip:
Phone:
FAX:
Email:
Name:
Title/Agency:
Address:
City/State/Zip:
Phone:
FAX:
Email:
A - 25
