5900-63 Qualified Product Information Form for Residential Venti

OMB Control No. 2060-0528

Approval Expires XX/XX/XX

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United States

ENVIRONMENTAL PROTECTION AGENCY

Washington, DC 20460

Qualified Product Information Form for Residential Ventilating Fans

Office of Atmospheric Programs

ENERGY STAR Product Information Form for Use by ENERGY STAR Qualified Residential Ventilating Fan Partners (Companies who have joined ENERGY STAR for Residential Ventilating Fans by signing the Partnership Agreement) You may use this form to report only those products that are sold under your company’s brand name. If your firm sells its models to another company that uses its own brand name, that company must join the program and report its own products. Information from this form will be added to the list of ENERGY STAR qualified residential ventilating fan products.

Product Contact Information:

(for verification of product information)

Name:

Tel:

Fax:

Email:

Company Name:

(As listed in Partnership Agreement)

Product Type (check one):

• Range Hood

• Bathroom/Utility Room Fan

• In-line (single-port)

• In-line (multi-port)

1. Qualifying Product Information

Brand	Model Name	Model Number	Warranty (yrs)	Date Product Available

2. Product Performance

Airflow (cfm)	Motor Wattage (W)	Efficacy (cfm/W)	Sound level (sones)*

* Sound level measurements not required for single and multi-port in-line fans.

Note: Ducted bathroom and utility room fans tested at 0.1 w.g. static pressure. Single and multi-port in-line fans tested at 0.2 w.g. static pressure. Non-ducted products tested at 0.3 w.g. static pressure. Range Hoods tested at Working Speed as defined in “HVI Supplement – Range Hood Working Speed.”

Ducted Bathroom and Utility Room Fans Only:

Airflow at 0.25 w.g. static pressure: ______ cfm ______ % of rated airflow at 0.1 w.g.

3. Testing and HVI Certification

Tested By: (Name of Independent Testing Firm or Self-Tested)

Date Tested:

Is the product in the Home Ventilating Institute Directory (HVI) (circle one)? Yes No

If so, under what name?

4. Lighting Requirements

All light sources: please complete the fields provided below (as applicable).

Fluorescent light sources: complete fields and provide data in table below.

Total Number of Lamps Used: ______

Maximum Total Listed Lamp Wattage: _____ watts

Maximum Total Night Light Wattage: ______ watts

Performance and Reporting Requirements for Fluorescent Sources
Ballast type (check one)	Electronic Magnetic
Ballast Manufacturer Name
Ballast Model Number
Lamp Manufacturer Name
Lamp Model Number
System Efficacy per Lamp Ballast Combination	Lumens
	_____ Input Watts
	_____ Lumens/Watt
Lamp Start Time	milliseconds
Lamp Life	hours
Color Rendering Index	CRI
Correlated Color Temperature	Kelvin
Noise	dBA
Does lamp ship with the unit (circle one)?	Yes No

5. Labeling Requirements

By checking the boxes below, you are confirming that you have reviewed and will meet the labeling requirements outlined in the ENERGY STAR Program Requirements for Residential Ventilating Fans. These requirements include:

On front of product (required)	In product literature (required)
On product packaging (recommended)	On Internet site (required)

If answer to any of the above is no, explain why:

5. Additional Information

Please list all major retailers that carry the product (attach a list if necessary):

Please check one or more of the following international markets where these products are sold (if applicable):

Australia/New Zealand	Japan
Canada	Mexico
EU	Taiwan

The public reporting and recordkeeping burden for this collection of information is estimated to average 4.85 hours per response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.

Please submit your completed QPI Form to ENERGY STAR for Ventilating Fans

Email: [email protected], Fax: (202) 862-1144

1725 Eye St., NW, Suite 1000, Washington, DC 20006

Energy Star, US EPA, 1200 Pennsylvania Ave., MC 6202J, Washington, DC 20460 USA

Toll-free number 1-888-STAR-YES, Web site http://www.energystar.gov

ENERGY STAR is a registered mark.

EPA Form No. 5900-63