Advice to Parent form

Advice to Parent form
This form documents the prescribed restraint for the child, the review period, and information about installation and use.

A separate form will need to be completed if the child is prescribed more than one type of restraint (e.g special purpose child restraint in family vehicle; harness in school bus).

This form meets the requirements of AS/NZS 4370:2013 Restraint of children with disabilities, or medical conditions, in motor vehicles and best practice.
Select your state or territory
Date

Day Month Year

Parent's/guardian's full name

First Name Last Name
Prescriber

AS/NZS 4370:2013 defines a prescriber as:

“The person or persons responsible for assessing an individual child’s needs and prescribing the way in which a child with a disability or medical condition should be transported in a motor vehicle. For example, occupational therapist, physiotherapist, medical practitioner, rehabilitation engineer.”
Prescriber's full name

First Name Last Name
Prescriber's occupation
Prescriber's occupation
Prescriber's organisation
Prescriber's email
example@example.com
Prescriber's phone number

Section 3

Important information for the parent/guardian about installing and using the prescribed restraint.
General

Install and use in accordance with the manufacturer's instructions. Use product as demonstrated by the supplier and/or prescriber. The Advice to Parent form must be carried in the vehicle the child is travelling in. It is important that the use of the product is reviewed on the date specified in this form.
Special purpose child restraints

The built-in harness is for postural support only. The vehicle seatbelt must be used by the occupant.
Seatbelt buckle covers

If your child attempts to remove the buckle cover, or tries to get out of the vehicle seat, advise the prescriber as the buckle cover may not be suitable. This is a significant road safety risk and requires urgent follow-up. To minimise road safety risks and driver distraction, it is recommended that your child is accompanied by an adult (other than the driver) when using the buckle cover for the first few trips. If your child attempts to remove the buckle cover, or slide out from under the seatbelt, advise the prescriber. This is a significant road safety risk and requires urgent follow-up. It is recommended for the first few trips that travel routes are selected that allow you to pull over quickly if needed (i.e avoid freeways and high-speed roads).
Other
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Section 1