## 1 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:

In vestigator 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 : Zi p Code: E

- mail:



## PART II

– Crib Safety Information

- 16 CFR Parts 1219 and 1220 ( A ttach 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)

1.

2.

3.

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

## 2 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 inform ation, 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 pro duct

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 wa s manufactured,

date and place where the product was tested

, and identification of the third p arty laboratory on whose testing the certificate depends.



## Part IV

– Compliance Date Awareness

Part V

- CPSC Information and Education Materials Delivered to Facility

Child Care Professionals, Safer Products.g ov

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:

_____________________________________________________________________________________________________________

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

If yes, how did they become aware?

CPSC Websi te

CPSC Educational Materials

State/Loc al Child Care Licensing Agency

Trade Associations

Federal Register

Other

## 3 Part VI

- Comments

Comments

__________________________________________________________________________________________________

________________________________________________________________ __________________________________

__________________________________________________________________________________________________

_________________________________________________________________________________________________

_____________________ ________ ______________________ ___________________ CPSC In vestigator

- Print Name Signature Date

CPSC Form N umber

________ 

## N ote: This form must be completed by CPSC staff or the designated s tate or local government

official.

The U.S. Consumer Product Safety Commission has requested approval from the Office of

Management and Budget for the collect ion 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.