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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)

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
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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

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:

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

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

If yes, how did they become aware?

CPSC Website

CPSC Educational Materials

State/Local Child Care Licensing Agency

Trade Associations

Federal Register

Other
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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.