Request for Virtual Car Seat Check—King County Public Health

To schedule a virtual car seat check, please provide all the information requested on this form. Please let the caregiver know that, after the form is submitted, we will email them so they can complete the hold-harmless agreement. Once we receive this form and the hold-harmless agreement, the caregiver should watch their email for a message from a technician, usually within a couple business days. If they don't hear from a technician after a few days, please send an email to [email protected] to let us know. NOTE: The information provided will not be shared with anyone or used for any purpose other than to assist the caregiver with the education that's been requested about proper car seat use.

A car seat checkup is an educational opportunity. To fully participate in an appointment, a caregiver must be sure to prepare in advance by reading the car seat and vehicle owner's manuals. Also, before the meeting, they should please try installing the car seat on their own. If the baby isn't born yet, they should plan to have a doll or stuffed animal on hand in order to practice harness use.

Caregiver Name*

Name of the person requesting a car seat check (parent, grandparent, nanny, etc.)

First Last

Email*

Enter Email Confirm Email

City/State/Zip Code*

City State ZIP Code

County*

Phone

Virtual Technology*

Most technicians default to using Zoom for virtual checkups. Please confirm that Zoom will work for you by marking it here. Also, please indicate any other technology options you are comfortable with, especially if you cannot use Zoom.

Zoom (preferred)
Teams
FaceTime
Skype
Google Duo

Person at KCPH referring this caregiver:*

Name of the KC Public Health employee. If the employee would like to be contacted to confirm check is complete, please add contact information here, as well.

Information about the child

Age of child*

Indicate the child's age or if you are still expecting the child. If you are doing checks for multiple children, please fill out a separate form for each child.

Child's Weight*

Enter the child's weight in pounds.

Child's Height*

Enter the child's height in inches.

If applicable, please describe any special needs that affect this child's use of a car seat:

Please describe other regular riders in rear seats, including siblings (whether or not also being checked). Please include ages and type of child restraint, as appropriate.

Car Seat Information

So we can prepare for your car seat check, please provide us with the following information about the car seat. If you need to pause to look for this information or don't have it yet, you can go to the bottom of this form to click "Save and Continue Later."

Car Seat Brand*

Scroll to find the car seat brand name.

Car Seat Model Name*

Car Seat Model Number*

Car Seat Manufacture Date*

Hint: Find the model number and manufacture date on a sticker on the car seat, on its base (if applicable), and/or on the registration card. The sticker is usually on the side, back, or underside of the car seat. If you have trouble finding the sticker, the owner's manual should help guide you to it. If you are still having trouble, you can email us at [email protected] for assistance. (If you do not have a car seat, enter zeros for this required information and explain further in the space provided at the end of this form.)

Vehicle Information

Please provide us with the following information about the vehicle. (If the caregiver does not have a vehicle, enter zeros in these required fields and provide more information about the situation in the field provided at the end of this form.)

Vehicle Brand (Make)*

Please indicate the vehicle brand (i.e.: Ford, Toyota, etc.)

Vehicle Model*

Please enter the vehicle model (i.e.: Explorer, Sienna, etc.)

Model Year*

Please enter the model year of your vehicle.

How many rows of seating does the vehicle have?*

One row (no back seat)
Two rows
Three rows
More than three (full-size van)

Other Information

Please use this space to share any additional details or further explain any responses.