CPSC Safety Standards for Full-Size and Non-Full-Size Baby Cribs Verification of Compliance Form

U.S. Consumer Product Safety Commission (CPSC)

Safety Standards for Full-Size Baby Cribs and Non-Full-Size Baby Cribs

16 CFR Parts 1219 and 1220

Verification of Compliance Form

PART I – Child Care Center Information OMB Control Number:

Investigator Name:			Date of Visit:
Facility Name:			License/Permit Number:
Address:	Phone Number:		Fax Number:
City:	State:		Zip Code:
Please indicate Facility Type: Example: Child Care Center, Family Child Care, etc.	E-mail Address:
	Responsible Jurisdiction:
Contact Name:	Title:
Contact Address (complete if different from above):	Phone Number:			Fax Number:
City:	State:	Zip Code:		E-mail:

PART II – Crib Safety Information - 16 CFR Parts 1219 and 1220 (Attach more sheets for Part II if necessary)

Total Number of Cribs in Facility
Crib	Date of Purchase	Manufacturer & Model	Manufacture Date	Children’s Product Certificate (Y/N)*	Tracking Label (Y/N)*	Registration Card (Y/N)*
4.
5.
6.

PART IIa – Provide the following pictures for each crib listed as attachments to this form:

1. Picture of Crib

2. Picture of Tracking Label

3. Picture of Crib Labeling

Part III - Definitions

Registration Card means a postage-paid consumer registration form provided by the manufacturer with each product. Registration Cards must identify the manufacturer’s name and contact information, model name, model number, and the date of manufacture.

Tracking Label means a permanent, distinguishing mark on the product and its packaging, to the extent practicable, which must contain certain basic information, including the source of the product, the date of manufacture, and cohort information, such as batch or run number.

Children’s Product Certificate (CPC) means a certificate that certifies that such children’s product complies with the children’s product safety rule based on the assessment of a third-party conformity assessment body accredited and accepted by the Commission to conduct such tests and identifies: the product covered by the certificate, the safety regulation to which the product is being certified, the importer or domestic manufacturer, contact information for the individual maintaining records of test results, date and place where the product was manufactured, date and place where the product was tested, and identification of the third party laboratory on whose testing the certificate depends.

Part IV – Compliance Date Awareness

Is the Child Care Provider aware of the December 28, 2012 Compliance Date? Yes No

If yes, how did they become aware?

C PSC Website

CPSC Educational Materials

S tate/Local Child Care Licensing Agency

T rade Associations

F ederal Register

O ther

Part V - CPSC Information and Education Materials Delivered to Facility

Child Care Professionals, Safer Products.gov

Neighborhood Safety Network Poster – A Safer Generation of Cribs

Child Care Providers – Your Guide to New Crib Standards

Sign up for Recalls

Other___________________

List additional CPSC Educational Materials requested _____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Mail Directly to Center? Yes______ No ________

Send to:

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Part VI - Comments

Comments __________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

_________________________________________________________________________________________________

_____________________________ ______________________ ___________________

CPSC Investigator - Print Name Signature Date

CPSC Form Number ________

Note: This form must be completed by CPSC staff or the designated state or local government official.

The U.S. Consumer Product Safety Commission has requested approval from the Office of Management and Budget for the collection of information associated with this form.  In the absence of such an approval, you are not required to provide the information requested to complete this form.

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