Car Seats Installation-Performance Tracking Form

Technician's Name*

First NameLast Name

Agency/Organization

Phone Number*

Area CodePhone Number

Email*

example@example.com

County*

Please select in which quarter the activity occured:*

January - MarchApril - JuneJuly - SeptemberOctober - December

In which year did the activity occur?*

Please list the number of seats inspected. (includes all inspections of installed seats, new installs, unrestrained, etc.)*

	#
Harnessed Rear Facing
Harnessed Forward Facing
Booster
Child with Adult Seat Belt
Unrestrained Child

How many of the above inspected arrived uninstalled?*

	#
Harnessed Rear Facing
Harnessed Forward Facing
Booster

Please list the total number of SEATS with errors, NOT the total number of errors. Please do not count new installations unless they were recalled/expired, or they selected the wrong seat for the child.*

	#
Recalled or expired seats
Erroneously selected seats
Erroneously installed seats
Seats with Erroneous Harnesses
Data not Available

Seats Distributed by Car Seats Colorado*

	#
Infant-Only
Convertible (Rear- or Foward-Facing) Seat
Combination (Forward-Facing or Booster) Seat
Booster Seat

Seats Distributed by All Others*

	#
Infant-Only
Convertible (Rear- or Foward-Facing) Seat
Combination (Forward-Facing or Booster) Seat
Booster Seat

Since you last reported how many community/educational events have you participated in?*

e.g., safety fairs; classes; presentations; check events

Excluding those you helped with seat checks, about how many people have heard your Car Seats Colorado message since you last reported?*

This number reflects those reached through personal interaction and NOT via mass media/marketing efforts.