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

This version of the form is not currently in use and is provided for reference only.
Download this version of Form CCL.005 for the current year.

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, 2017;
  • 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. 3/2017
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. 3/2017
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)