NHTSA 1111 ATT C7 Inspection-Vehicle Restraints

ATTACHMENT C7

Paperwork Reduction Act Burden Statement

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2127-0642. Public reporting for this collection of information is estimated to be approximately 0 minutes per response, including the time for reviewing instructions, completing and reviewing the collection of information. All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, National Highway Traffic Safety Administration, 1200 New Jersey Ave, S.E., Washington, DC, 20590. NHTSA Form 1 111

United States Department of Transportation National Highway Traffic Safety Administration	Inspection Form Vehicle Restraints (03/10/11 Draft)		Form Approved O.M.B. No. 2127-0642 Expiration Date: xxxx National Automotive Sampling System National Child Restraint Use – Special Study
Primary Sampling Unit Number: _____ _____		Site Number: _____ _____
O bservation Number: _______/_______		Date of Observation: _______/_______/2011
Vehicle Identification Number (VIN) [Left justify; Slash zeros and letter Z; If Unknown, Code all nines] ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Number of vehicle seating positions: _______________________
Observe the Availability & Use of Restraints for Each of the Seating Positions For each seating position: Scribble over or make an “X” for the following: “Available” and “Used” Boxes. If the seating position is not available in the vehicle “ Used” Boxes: if no one is sitting in an available seating position Abbreviations: 1st line: L/S (Lap-Shoulder), L (Lap), or S (Shoulder) Belt; DK (Don’t Know), U (Unrestrained) 2nd line: T-S (Tether Anchor-Shelf), T-O (Tether Anchor-Other Location) 3rd Line: LA-L/R (Both Lower Anchors), LA-L (Lower Anchor-Left), LA-R (Lower Anchor-Right) 4th & 5th Lines: I-w/B (Infant w/base), I-w/o (Infant w/o Base), RFC (RF Convertible/all-in-one), FFC (FF Convertible or Combination w/harness/shield), (INT) Integrated CRS, HB-BPB (HB BP booster-no harness), BL-BPB (Backless BP booster), S (Shield Booster), C (Car bed), V (Vest), O (Other)

Front of Vehicle
11A Available L/S L S DK	12A Available L/S L S DK T-S T-O DK LA-L/R LA-L LA-R DK	13A Available L/S L S DK T-S T-O DK LA-L/R LA-L LA-R DK
11B Used L/S L S DK U	12B Used L/S L S DK U T-S T-O DK LA-L/R LA-L LA-R DK I-w/B I-w/o RFC FFC INT HB-BPB BL-BPB S C V O	13B Used L/S L S DK U T-S T-O DK LA-L/R LA-L LA-R DK I-w/B I-w/o RFC FFC INT HB-BPB BL-BPB S C V O

21A Available L/S L S INT DK T-S T-O DK LA-L/R LA-L LA-R DK	22A Available L/S L S INT DK T-S T-O DK LA-L/R LA-L LA-R DK	23A Available L/S L S INT DK T-S T-O DK LA-L/R LA-L LA-R DK
21B Used L/S L S DK U T-S T-O DK LA-L/R LA-L LA-R DK I-w/B I-w/o RFC FFC INT HB-BPB BL-BPB S C V O	22B Used L/S L S DK U T-S T-O DK LA-L/R LA-L LA-R DK I-w/B I-w/o RFC FFC INT HB-BPB BL-BPB S C V O	23B Used L/S L S DK U T-S T-O DK LA-L/R LA-L LA-R DK I-w/B I-w/o RFC FFC INT HB-BPB BL-BPB S C V O

31A Available L/S L S INT DK T-S T-O DK LA-L/R LA-L LA-R DK	32A Available L/S L S INT DK T-S T-O DK LA-L/R LA-L LA-R DK	33A Available L/S L S INT DK T-S T-O DK LA-L/R LA-L LA-R DK
31B Used L/S L S DK U T-S T-O DK LA-L/R LA-L LA-R DK I-w/B I-w/o RFC FFC INT HB-BPB BL-BPB S C V O	32B Used L/S L S DK U T-S T-O DK LA-L/R LA-L LA-R DK I-w/B I-w/o RFC FFC INT HB-BPB BL-BPB S C V O	33B Used L/S L S DK U T-S T-O DK LA-L/R LA-L LA-R DK I-w/B I-w/o RFC FFC INT HB-BPB BL-BPB S C V O

E xtra Seating Positions ( Identify each location)

____ A/B Available/Used L/S L S DK INT U T-S T-O DK LA-L/R LA-L LA-R DK I-w/B I-w/o RFC FFC INT HB-BPB BL-BPB S C V O

____ A/B Available/Used L/S L S DK INT U T-S T-O DK LA-L/R LA-L LA-R DK I-w/B I-w/o RFC FFC INT HB-BPB BL-BPB S C V O

____ A/B Available/Used L/S L S DK INT U T-S T-O DK LA-L/R LA-L LA-R DK I-w/B I-w/o RFC FFC INT HB-BPB BL-BPB S C V O