Child Restraint Observation Survey
Child restraint observation survey
Site:Date:Time: Surveyor:
Use one panel per vehicle, with one row for each child. If there are more than 4 children in the vehicle, use the next panel as well and write "one vehicle" between them. A red pen is most helpful for the person entering the data.
"Suitable" means an available restraint which was appropriate for the age of the child. "Other" means one which was suitable only for an older child, eg an adult seatbelt.
Child / Seating position(Front, Rear, Luggage) / Restraint used (circle one) / If NONE or KNEE, what restraint available? / Child Age
0-4 5+
1 / F / R / L / Baby / Child / bOost / Harness / Seatbelt / None / Knee / Suitable / Other / None / 1 / 2
2 / F / R / L / Baby / Child / bOost / Harness / Seatbelt / None / Knee / Suitable / Other / None / 1 / 2
3 / F / R / L / Baby / Child / bOost / Harness / Seatbelt / None / Knee / Suitable / Other / None / 1 / 2
4 / F / R / L / Baby / Child / bOost / Harness / Seatbelt / None / Knee / Suitable / Other / None / 1 / 2
Driver / Sex: / M / F / Seatbelt worn? / Y / N / D
Child / Seating position
(Front, Rear, Luggage) / Restraint used (circle one) / If NONE or KNEE, what restraint available? / Child Age
0-4 5+
1 / F / R / L / Baby / Child / bOost / Harness / Seatbelt / None / Knee / Suitable / Other / None / 1 / 2
2 / F / R / L / Baby / Child / bOost / Harness / Seatbelt / None / Knee / Suitable / Other / None / 1 / 2
3 / F / R / L / Baby / Child / bOost / Harness / Seatbelt / None / Knee / Suitable / Other / None / 1 / 2
4 / F / R / L / Baby / Child / bOost / Harness / Seatbelt / None / Knee / Suitable / Other / None / 1 / 2
Driver / Sex: / M / F / Seatbelt worn? / Y / N / D
Child / Seating position
(Front, Rear, Luggage) / Restraint used (circle one) / If NONE or KNEE, what restraint available? / Child Age
0-4 5+
1 / F / R / L / Baby / Child / bOost / Harness / Seatbelt / None / Knee / Suitable / Other / None / 1 / 2
2 / F / R / L / Baby / Child / bOost / Harness / Seatbelt / None / Knee / Suitable / Other / None / 1 / 2
3 / F / R / L / Baby / Child / bOost / Harness / Seatbelt / None / Knee / Suitable / Other / None / 1 / 2
4 / F / R / L / Baby / Child / bOost / Harness / Seatbelt / None / Knee / Suitable / Other / None / 1 / 2
Driver / Sex: / M / F / Seatbelt worn? / Y / N / D
Child / Seating position
(Front, Rear, Luggage) / Restraint used (circle one) / If NONE or KNEE, what restraint available? / Child Age
0-4 5+
1 / F / R / L / Baby / Child / bOost / Harness / Seatbelt / None / Knee / Suitable / Other / None / 1 / 2
2 / F / R / L / Baby / Child / bOost / Harness / Seatbelt / None / Knee / Suitable / Other / None / 1 / 2
3 / F / R / L / Baby / Child / bOost / Harness / Seatbelt / None / Knee / Suitable / Other / None / 1 / 2
4 / F / R / L / Baby / Child / bOost / Harness / Seatbelt / None / Knee / Suitable / Other / None / 1 / 2
Driver / Sex: / M / F / Seatbelt worn? / Y / N / D
baby seat child seat booster seat harness seatbelt
05/19/2019 : g:\ljp\surveys\Child\SRVYFORM2.DOC