Please complete this form to submit your information:

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Contact a Child Passenger Safety Technician

Please complete the following information to be contacted by a Child Passenger Safety Technician

What is your primary question regarding transporting children with special health care needs?
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What is your relationship to this child? Are you the parent or legal guardian of this child?
Yes
No
If no, please explain:
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The following specific information will assist us in helping you:

Age of child

Weight of child

Height of child

Medical diagnosis (If more than one, please list):
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Can the child sit up unassisted?
Yes
No
If no, please explain:
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Who will be transporting this child (parent, child care provider, school bus driver)? List all that apply.
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How are you currently transporting the child?
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If you are using a car seat:

Who is the manufacturer (i.e. Evenflo, Graco, etc.)

Model number

Year of manufacture

Is this a second- hand car seat?
Yes
No

What is the year, make and model of your vehicle? How many seat belts are available and are they lap belts only or lap/shoulder belts?
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Do you have tether anchor points in your vehicle?
Yes
No

How is the child being transported to school?
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Does the child have casts or braces on the legs?
Yes
No
If yes, please explain:
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Does the child require the use of special equipment (i.e. monitor, oxygen). Please List.
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Does the child have a tracheotomy tube?
Yes
No

Does the child have a feeding tube?
Yes
No

Does the child need to be seated in a reclined position?
Yes
No
If yes, please explain:
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Would the child need to lie down while being transported in a vehicle for medical reasons?
Yes
No
If yes, tummy or back? Explain:
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What Ohio county do you live in?
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If you are not from Ohio, what state do you live in?
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Does your child have a physical or occupational therapist?
Yes
No

Is your child currently working with a health care professional?
Yes
No

Do you receive financial assistance for this child?
Yes
No

Response to this request will be by telephone or e-mail within five business days. Please choose your preference of return contact:
E-mail address:

Daytime telephone number: