5900-71 Qualified Product Information Form for Indoor Residentia

OMB Control No. 2060-0528

Approval Expires XX/XX/XX

United States ENVIRONMENTAL PROTECTION AGENCY Washington, DC 20460 INDOOR Qualified Product Information Form for Indoor Residential Light Fixtures Office of Atmospheric Programs
ENERGY STAR product information form for use by ENERGY STAR qualified residential light fixture partners (Companies who have joined ENERGY STAR for residential light fixtures by signing a Partnership Agreement) You may use this form to report those products that are sold under your company’s brand name. If your firm sells models (fixtures) under a brand name different from your company name, you must list the brand name and the associated retailer/organization. Please copy this form and return one for each lamp/ballast combination to the address below.
MANUFACTURER (ENERGY STAR Partner): ____________________________­­­­­­____________________________________________
SECTION I -- LAMP & BALLAST INFORMATION:
Number of Lamps/ Fixture	Number of Ballasts/ Fixture	Individual Listed Lamp Wattage	Lamp Type1	Lamp Size2	Lamp (e.g., lightbulb) Manufacturer & Model Number	Ballast Manufacturer & Model Number

ENERGY STAR should review this submittal as a (circle one): Lamp &/or Ballast Platform3 Complete Fixture Both
1. Lamp Type: For example, CFL = Compact Fluorescent, CR = Circular, L = Linear 2. Lamp Size: For example, T4, T5, or T8. 3. A lamp and ballast platform does not receive the ENERGY STAR mark and cannot be promoted as an ENERGY STAR qualified product. Rather, you may promote the “qualified” lamp, ballast, or lamp/ballast platform as a component that meets applicable ENERGY STAR Program Requirements when used in ENERGY STAR qualified residential light fixtures.
SECTION II -- TEST RESULTS: Enter results from test report (complete using average of tested samples) or manufacturer data as specified in the ENERGY STAR Program Requirements for Residential Light Fixtures Version 4.0 and attach required documentation to this form.
Performance Characteristic	Test Result				Required Documentation (please attach to this form)
Combined Lamp & Ballast Requirements
System Efficacy	__________	Total Lumen Output			Test report from a lab accredited by NVLAP or one of its MRA signatories, an EPA approved Platform Letter of Qualification, or EPA-approved documentation from an industry association.
	__________	Input Power (watts)
	__________	Lumens Per Watt
Lamp Requirements
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 Index	__________	CRI			Test report from a lab accredited by NVLAP or one of its MRA signatories, an EPA approved Platform Letter of Qualification, or EPA-approved documentation from an industry association.
Lamp Correlated Color Temperature (CCT)	Target CCT (circle one)	2700K	3000K	3500K	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 from an ISO 9000 registered facility.
		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.

SECTION II -- TEST RESULTS (continued): Enter results from test report (complete using average of tested samples) or manufacturer data as specified in the ENERGY STAR Program Requirements for Residential Light Fixtures Version 4.0 and attach required documentation to this form.
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, an EPA approved Platform Letter of Qualification, EPA-approved documentation from an industry association, or a test report from an OSHA NRTL laboratory.
Ballast Case Hot Spot Location	Check box if hotspot diagram has been included with this submittal:				Ballast manufacturer documentation.
Maximum Recommended Ballast Case Temperature During Normal Operation Inside A Fixture	___________		degrees Celsius		Ballast manufacturer documentation.
Maximum Measured Ballast Case Temperature During Normal Operation Inside Fixture(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	__________		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	Check box if ballast meets transient protection requirements:
End of Life Protection (Only required for ballasts with lamps sized T5 & smaller)	Testing requirements met?		Yes OR N/A		For T4 and T5 lamps, 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. For T3 lamps and smaller, a circuit diagram and engineering description.
	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, except when torchiere fixtures are submitted.
	Check one box if ballast is dimming-capable:			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.
Line Voltage Socket (LVS) Standard Design	Do any of the submitted fixtures use the twist-and-lock LVS standard design?	Yes OR No			No documentation required at time of submittal.
Line Voltage Socket (LVS) Standard Design with Self-Ballasted Pin-Based Lamp	Do any of the submitted fixtures ship with self-ballasted pin-based lamps (i.e., integrated lamp and ballast) that use the twist-and-lock LVS standard design?	Yes OR No			No documentation required at time of submittal.
Fixture Requirements (Only required for fixture submittals. Leave blank for lamp/ballast platform submittals.)
Fixture Warranty	Check box if fixture warranty is included with fixture packaging:				Provide two-year fixture manufacturer written warranty language that is included with product packaging.
Noise	__________		dBA		No documentation required at time of submittal.
SECTION II -- TEST RESULTS (continued): Enter results from test report (complete using average of tested samples) or manufacturer data as specified in the ENERGY STAR Program Requirements for Residential Light Fixtures Version 4.0 and attach required documentation to this form.
Replaceable Ballast	Check box if the submitted fixtures meet 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 – Portable Fixtures	Listed for Safety?	Yes OR N/A			Cover page of a safety test report or a general coverage statement.
Safety – Hardwired Fixtures	Listed for Safety?	Yes OR N/A			Cover page of a safety test report or a general coverage statement.
Decorative LEDs	Do any of the submitted fixtures use decorative LEDs?	Yes OR No			Manufacturer documentation including total wattage consumed by all LEDs, manufacturer warranty, and spec. sheet showing wattage, efficacy, LED life, color, and lumen depreciation.
Permanent Conversions	Do any of the submitted fixtures use a factory-installed device to permanently convert an Edison lamp base to a pin-base for fluorescents?	Yes OR No			No documentation required at time of submittal.
Product Packaging for Consumer Awareness Requirements	For fixtures that are not shipped with lamps:				Written copy or PDF graphic of the language that will be displayed on product packaging and within the packaging, as required.
	Does the packaging include a NEMA or ANSI generic lamp description, including a color designation?	Yes N/A
	Does the packaging suggest that the consumer select a lamp with a rated lamp life of 10,000 hours or more?	Yes N/A
	For fixtures that are shipped with lamps:
	Does the packaging clearly describe the target CCT designation in Kelvin?	Yes N/A
	For recessed downlight fixtures that are IC-Rated:
	Does the packaging clearly state this rating?	Yes N/A
	For recessed downlight fixtures that are Air-Tight (AT) rated:
	Does the packaging include an “air-tight” or similar designation to clearly show that the fixture produces less air leakage than 2.0 CFM at 75 Pascals when tested in accordance with ASTM E283?	Yes N/A
	Is the fixture itself labeled “air tight,” or similar designation?	Yes N/A
	Are installation instructions included?	Yes N/A
ADDITIONAL TEST RESULTS FOR INDOOR RECESSED DOWNLIGHT RETROFIT KITS ONLY: When qualifying a recessed downlight retrofit kit for ENERGY STAR, the following documentation must be provided in addition to the information required above.
Reflector Type	__________				No supplemental documentation required
Aperture Size	__________	Inches			No supplemental documentation required
Air Tight For Restricted Air Movement	Check box if submitted fixtures meet air tight requirement:				Manufacturer or laboratory data
Electrical Connections	Check box if submitted fixtures have an Edison lamp socket with wire “pigtail” to the ballast:				Manufacturer engineering description and/or diagram describing electrical connection
Safety – Fixture Conversions, Retrofits	Check box if submitted fixtures meet safety requirements for conversions & retrofits:				Cover page of a safety test report or a general coverage statement included
Product Packaging for Consumer Awareness Requirements	Fixture Compatibility List?	Yes N/A			Written copy or PDF graphic of the language that will be displayed on product packaging as well as installation instructions
	ASTM E283 Compliance Language?	Yes N/A
	Installation Instructions?	Yes N/A

SECTION III -- FIXTURE MODELS WITH SAME LAMP/BALLAST COMBINATION:
Please complete “Section 8 Fixture Model Info” in the Supplemental Information Reporting (SIR) form associated with this QPI form. The “Fixture Model Info” section of the SIR form contains fields to enter “Manufacturer Model Number/Retail SKU,” “Brand Name,” “Fixture Type,” “Does the lamp ship with fixture?,” “Date Available on the Market,” “Typed Fixture Description(s),” and “Intended Use.”
SECTION IV -- MARKETING REQUIREMENTS:
Upon approval of this product, the Partner will take steps to ensure that the ENERGY STAR mark will appear (check all that apply):
___ On product packaging (required) ___ In product literature (required) ___ On Internet site (required)
Note: Manufacturers are strictly prohibited from labeling, promoting, or marketing products as ENERGY STAR Qualified before receiving EPA notice of qualification.
Following ENERGY STAR acceptance of a product, partner has 90 days to fulfill the labeling requirements. ENERGY STAR reserves the right to remove a non-compliant product from the Web site after 90 days. Explain briefly in writing how you plan to implement the above listed labeling requirements within the timeline (use additional pages if necessary):
__________________________________________________________________________________________
__________________________________________________________________________________________
SECTION V -- SUBMITTAL PROCEDURE:
1.	Complete all required data fields in one RLF Supplemental Information	3.	Fill out one form for each lamp/ballast combination
	Reporting (SIR) form to be associated with one Qualified Product Information		(note: multiple fixtures can be associated with one platform)
	Reporting Form (QPI - this document). Refer to SIR “Instructions” Section for	4.	Attach and email the compiled submittal:
	further guidance		• one (1) QPI form, and
2.	Fill out entire RLF QPI form based on requirements for submittal type (“Lamp		• one (1) RLF SIR form
	&/or Ballast Platform,” “Complete Fixture,” or “Both”)	5.	Email to: [email protected]
SECTION VI -- VERIFICATION: (To be signed by senior representative of the fixture manufacturer)
I declare that the above information is accurate and true to the best of my knowledge. I understand that if any of the above information is found to be inaccurate by ENERGY STAR or any of ENERGY STAR’s contractors that the products listed above will be removed from the ENERGY STAR qualified product list. EPA may also choose to terminate the fixture manufacturer’ Partnership Agreement.
Typed Name: ________________________ Contact Email Address (required): __________________________ Date: ________________________ Contact Telephone Number (optional): __________________________

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.

Revised – February 2006 Version 4.0

EPA Form No. 5900-71