Form CCL.005 "Yearly Mechanical Safety Check for Vehicles Used to Transport Children in a Child Care Facility" - Kansas

What Is Form CCL.005?

This is a legal form that was released by the Kansas Department of Health & Environment - a government authority operating within Kansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2020;
  • The latest edition provided by the Kansas Department of Health & Environment;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CCL.005 by clicking the link below or browse more documents and templates provided by the Kansas Department of Health & Environment.

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Download Form CCL.005 "Yearly Mechanical Safety Check for Vehicles Used to Transport Children in a Child Care Facility" - Kansas

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Kansas Department of Health and Environment
CCL. 005
Rev. 3/2020
Bureau of Family Health
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Child Care Program:
(785) 296 -1270 Fax: (785) 559-4244
Website: www.kdheks.gov/kidsnet
YEARLY MECHANICAL SAFETY CHECK
FOR VEHICLES USED TO TRANSPORT CHILDREN IN A CHILD CARE FACILITY
Complete a form for each vehicle used to transport children. A record of the check and corrections shall be
kept on file at the facility or in the vehicle.
In accordance with K.A.R. 28-4-130(a)(2)(B), a yearly mechanical safety check has been completed on the items
listed for the vehicle identified on this form:
Tires
Make of car:
Year:
Lights
Windshield wipers
Number of individual restraints:
Horn
Signal lights
Vehicle Insurance Policy No:
Steering
Suspension
In accordance with K.A.R. 28-4-130(a) (3), liability limits are:
Glass
Brakes
Personal injury or death in any one accident:
Tail lights
Personal injury or death to two or more
Exhaust system
persons in any one accident:
Outside mirror
Loss of property:
The safety check may be completed by the applicant or any designee who agrees to attest to vehicle safety. The
safety check was completed by ___________________________________ on_______________________.
First
Last
(MM/DD/YYYY)
In accordance with K.A.R. 28-4-130(a)(4)(B), a first aid kit is required in vehicles transporting children. The first aid
kit contains the following:
Band-aids (all sizes)
1 pkg. gauze squares
Cleansing agent (green soap, pump soap antiseptic ointment or spray is acceptable)
1 elastic bandage
Adhesive tape
Roll of gauze
Scissors
_______________________________________________________
Facility Name Exactly as it Appears on the License
License Number
__________________________________________________________________________________________
Street Address
City
County
I attest that this information is true and correct.
_______________________________________________________
Signature for Facility
Date
(MM/DD/YYYY)
Kansas Department of Health and Environment
CCL. 005
Rev. 3/2020
Bureau of Family Health
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Child Care Program:
(785) 296 -1270 Fax: (785) 559-4244
Website: www.kdheks.gov/kidsnet
YEARLY MECHANICAL SAFETY CHECK
FOR VEHICLES USED TO TRANSPORT CHILDREN IN A CHILD CARE FACILITY
Complete a form for each vehicle used to transport children. A record of the check and corrections shall be
kept on file at the facility or in the vehicle.
In accordance with K.A.R. 28-4-130(a)(2)(B), a yearly mechanical safety check has been completed on the items
listed for the vehicle identified on this form:
Tires
Make of car:
Year:
Lights
Windshield wipers
Number of individual restraints:
Horn
Signal lights
Vehicle Insurance Policy No:
Steering
Suspension
In accordance with K.A.R. 28-4-130(a) (3), liability limits are:
Glass
Brakes
Personal injury or death in any one accident:
Tail lights
Personal injury or death to two or more
Exhaust system
persons in any one accident:
Outside mirror
Loss of property:
The safety check may be completed by the applicant or any designee who agrees to attest to vehicle safety. The
safety check was completed by ___________________________________ on_______________________.
First
Last
(MM/DD/YYYY)
In accordance with K.A.R. 28-4-130(a)(4)(B), a first aid kit is required in vehicles transporting children. The first aid
kit contains the following:
Band-aids (all sizes)
1 pkg. gauze squares
Cleansing agent (green soap, pump soap antiseptic ointment or spray is acceptable)
1 elastic bandage
Adhesive tape
Roll of gauze
Scissors
_______________________________________________________
Facility Name Exactly as it Appears on the License
License Number
__________________________________________________________________________________________
Street Address
City
County
I attest that this information is true and correct.
_______________________________________________________
Signature for Facility
Date
(MM/DD/YYYY)