5900-65 Qualified Product Information Form for Residential Ceili

OMB Control No. 2060-0528

Approval Expires XX/XX/XX

United States

ENVIRONMENTAL PROTECTION AGENCY

Washington, DC 20460

Qualified Product Information Form for Residential Ceiling Fans

Office of Atmospheric Programs

ENERGY STAR^® product information form for use by ENERGY STAR qualified residential ceiling fan partners

(Companies who have joined ENERGY STAR for residential ceiling fans by signing a Partnership Agreement)

You may use this form to report only those products that are sold under the company’s brand name. If your firm sells its models to another company that uses its own brand name, that company must join ENERGY STAR and report its own products. Information from this form will be added to the list of ENERGY STAR qualified residential ceiling fan products. Please copy this form and return one for each qualifying product model to the address provided in Section IX of this form.

Company Name: Product Contact Information

(As listed in Partnership Agreement) (verification of product information)

Name:

Product Type (check one):

• Ceiling Fan only

• Ceiling Fan with Light Kit – Pin Based CFLs

• Light Kit Only – Pin Based

Tel:

Fax:

Email:

1. Product Information – List representative (tested) model first. Models that are identical to the representative model in every respect but finish may be listed in the table below.

Brand Name	Model Name	Model Number*	Retailer SKU Number (if available)	Lamp Shipped w/ Model? (Light Kits only)
				Y OR N
				Y OR N
				Y OR N
				Y OR N
				Y OR N
				Y OR N
Fan Size (in.):	Please Attach Fixture Description (Light Kit)1

* Please include available finishes for the representative model; use additional sheets, if necessary, and attach to this QPI form.

2. Ceiling Fan Airflow Efficiency

Fan Speed	Airflow (CFM)	Fan Power Consumption (watts)	Airflow Efficiency (CFM/watt)

3. Ceiling Fan Controls

Provide type and location of fan controls (wall-mounted switch, pull chain, remote control):

Type of Fan Speed Control	Location of Fan Speed Control	Type of Airflow Direction Control	Location of Airflow Direction Control

4. Lighting Requirements (for all ceiling fan light kits: integral, attachable, or sold separately)

Pin-Based: Light kit must be tested and qualify under Appendix A of the ENERGY STAR Version 2.1 Residential Ceiling Fan specification. Please provide test results in Section VIII of this form. Testing documentation must be submitted with this form. Note: If lamp/ballast combination has already been tested by OEM or other entity, you may submit an ENERGY STAR lamp/ballast qualification letter (provided by the OEM) in lieu of testing documentation, where applicable. Please note that some additional documentation may be required for qualification.

Manufacturer Model/Product #

CFL Wattage Number of CFLs Included in Packaging

5. Warranty Requirements

Note: Ceiling fans and/or light kits must meet the following minimum requirements:

Motor: > 30 years

Fan Components: > 1 year

Light Kits: > 2 years

Motor Warranty: years

List Fan Components and their Warranties:

Light Kit Warranty: years

6. 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 Ceiling Fans. These requirements include:

 On product packaging/box  In product literature  On Internet site

Will the Performance and Efficiency Table be clearly displayed on the outside of the product packaging (Ceiling Fans only)?  Yes  No

7. Ceiling Fan Testing

All manufacturers are required to perform tests on residential ceiling fan models by using the Solid State Test Method described in the Testing Facility Guidance Manual: Building a Test Facility and Performing the Solid State Test Method for ENERGY STAR Qualified Ceiling Fans. Fan models identical in every respect but finish may be represented by a single representative model for testing purposes. However, separate test data is required for all models that differ in motor type or size, housing size/shape/design, rotational speed, control type, or blade weight, number, size, or pitch. Laboratory test results must be attached to this form for a model to qualify as ENERGY STAR.

Tested By: Date Available (on market):

(Name of Qualified Testing Facility)

8. Light Kit Test Results

Note: Data and information needed to complete this section can be provided by an accredited public or private laboratory, by the OEM, or from an industry association, with the exception of the 2-year warranty and Safety Documentation, which should be supplied by the ceiling fan manufacturer. Values provided in the testing documentation must match those values that are entered in the Test Results table, below.

Please check if applicable:

• Submittal includes an ENERGY STAR lamp/ballast qualification letter for Version 4.0 of the Indoor Residential Lighting Fixture Specification.

LAMP & BALLAST INFORMATION:
*Number of Lamps/ Fixture	Number of Ballasts/ Fixture	*Individual Listed Lamp Wattage	*Lamp Type1	Lamp Size2	Lamp (e.g., light bulb) Manufacturer & Model Number	Ballast Manufacturer & Model Number
1. Lamp Type: For example, CFL = Compact Fluorescent, CR = Circular, L = Linear 2. Lamp Size: For example, T4, T5, or T8.
(For ENERGY STAR use only) Generic Lamp Code:

TEST RESULTS: Enter results from test report (complete using average of three or more samples) or manufacturer data as specified in the ENERGY STAR Program Requirements for Residential Light Fixtures Version 3.2 and attach required documentation to this form.
Performance Characteristic	Test Result					Required Documentation (please attach to this form)
Efficacy	__________	Total Lumen Output [2]				Test report from a lab accredited by NVLAP or other EPA approved documentation.
	__________	*Input Power (watts) [3]
	__________	Lumens Per Watt
Lamp Life	__________	Average Rated Hours				Test report from a lab accredited by NVLAP or one of its MRA signatories, an EPA approved Platform Letter of Qualification, EPA-approved documentation from an industry association, or a test report from an ISO 9000 registered facility.
Lumen Maintenance	__________	% of initial lumens at 40% rated lamp life (4,000 hour minimum)
*Lamp Color Rendering (CRI)	__________	CRI				Test report from a lab accredited by NVLAP or other EPA approved documentation.
*Lamp Correlated Color Temperature (CCT)	Target CCT (circle one)	2700K		3000K	3500K	Test report from a lab accredited by NVLAP or other EPA approved documentation.
		4100K		5000K	6500K
	Samples falling within 7-step Mac Adam ellipse	_______ %
Lamp/Lampholder Compatibility	List ANSI-IEC Designated Lamp Base Type	_______				No documentation required at time of submittal.
	ANSI-IEC Standardized Lamp?	Yes OR No				For fixtures that do not use an ANSI-IEC standardized lamp from ANSI C78.901 & C78.81 or IEC 60901 & 60081, supply a lamp manufacturer specification sheet.
	If “Yes”, list ANSI-IEC Lamp Standard Data Sheet Number	_______ OR N/A
Lamp Labeling Requirement	Check box if lamp labeling requirement has been met:					A copy of the actual language that will be included on the lamp base or glass.
Ballast Requirements
Lamp Start Time	__________	Milliseconds				Test report from a lab accredited by NVLAP or one of its MRA signatories, an EPA approved Platform Letter of Qualification, EPA-approved documentation from an industry association, or a test report from an OSHA NRTL laboratory.
Power Factor	__________					Test report from a lab accredited by NVLAP or one of its MRA signatories, an EPA approved Platform Letter of Qualification, EPA-approved documentation from an industry association, or a test report from the ballast or fixture manufacturer.
Lamp Current Crest Factor	__________					Test report from a lab accredited by NVLAP, or one of its MRA Signatories, or a lab accredited by an OSHA NRTL, or other EPA approved documentation
Maximum Recommended Ballast Case Temperature During Normal Operation Inside Light Kit(s)	___________	degrees Celsius				Manufacturer or laboratory data
Maximum Measured Ballast Case Temperature During Normal Operation Inside Light Kit(s)	___________	degrees Celsius				Test report from a lab accredited by NVLAP or one of its MRA signatories, an OSHA NRTL laboratory, or the fixture or ballast manufacturer.
Electromagnetic and Radio Frequency Interference	Check box if the ballast meets FCC requirements for consumer use:					No documentation required at time of submittal.
Ballast Frequency (Required for all electronic ballasts)	__________	kHz				Test report from a lab accredited by NVLAP or one of its MRA signatories, an EPA approved Platform Letter of Qualification, EPA-approved documentation from an industry association, or a test report from the ballast or fixture manufacturer.
Transient Protection (Required for all electronic ballasts)	Check box if ballast meets transient protection requirements:
End of Life Protection (Required for electronic ballasts with lamps sized T5 & smaller)	Testing requirements met?		Yes OR N/A			Manufacturer data or laboratory engineering description outlining the scheme that is used to achieve end of life function within the ballast
	Maximum number of lamps shut down when lamp end of life event occurs:		_______ OR N/A
Dimming	Dimming-Capable Ballast?	Yes OR No				No documentation required at time of submittal.
	If “Yes”, Indicate Dimming Mechanism	3-Way Switching Continuous Dimming
Safety – Ballasts and “Non Edison base Fluorescent Adapters”	Listed for Safety?	Yes OR N/A				Cover page of a safety test report or a general coverage statement.
Light Kit Requirements
Light Kit Warranty	Check box if fixture warranty is included with light kit packaging:					2-Year Written Fixture Warranty
Noise	__________	dBA				Manufacturer or laboratory data
Lamp Shipment Requirement	Lamp(s) intended for use with light kit(s) included?					No documentation required at time of submittal.
Replaceable Ballast	Check box if the submitted light kit(s) meet(s) the replaceable ballast requirement:					A copy of the language that includes guidance on ballast replacement and states that the ballast is replaceable with the use of a “qualified electrician” without the cutting of wires.
Safety – Hardwired Fixtures	Listed for Safety?	Yes OR N/A				Cover page of a safety test report or a general coverage statement included
Product Packaging for Consumer Awareness Requirements	Does the packaging clearly describe the target CCT designation in Kelvin?	Yes OR N/A				Written copy or PDF graphic of the language that will be displayed on product packaging and within the packaging, as required.

* Items with an asterisk will appear on the ENERGY STAR Web site.

9. 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  Canada  EU  Japan  Mexico  Taiwan

This Qualified Product Information Form and the Program Requirements for Residential Ceiling Fans can be found in the Partner Resources section of the ENERGY STAR Web site at www.energystar.gov.

Please submit your completed Qualified Product Information Form and testing documentation one of the following ways:

E-mail testing results/QPI forms to [email protected]

Fax results/QPI forms to Rebecca Duff at (202) 862-1144

US Mail/Overnight/Express results/QPI forms to: Rebecca Duff, ICF International, 1725 Eye Street NW, Suite 1000, Washington, DC 20006

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.

1 The fixture description should include brief information about finish, glass types, and any other aesthetics for consumer benefit. Descriptions may be submitted either electronically or as an attachment to this form.

2 Total Lumen Output = (Lumens) x (# Lamps per Fixture) x (# Ballasts per fixture) x (Ballast Factor)

3 From ballast specification

Please submit your completed QPI Form to ENERGY STAR for Ceiling 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. 5900-65