5900-72 Qualified Product Information Form for Outdoor Residenti

OMB Control No. 2060-0528

Approval Expires XX/XX/XX

United States ENVIRONMENTAL PROTECTION AGENCY Washington, DC 20460 Q OUTDOOR ualified Product Information Form for Outdoor 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	Ballast Type (circle one)	Lamp (e.g., lightbulb) Manufacturer & Model Number			Ballast Manufacturer & Model Number (Note: If no ballast is used, write “N/A”)
					Electronic
					Magnetic
					N/A
1. Lamp Type: For example, FL = Fluorescent, INC = Incandescent, MH = Metal Halide, HPS = High Pressure Sodium, HAL = Halogen
SECTION II -- TEST RESULTS: (Complete using average of tested samples)
Performance Characteristic			Test Result					Required Documentation (please attach to this form)
Compliance With Outdoor Specification Table 2A OR Table 2B
Combined Lamp & Ballast Requirements: (To be completed if using Table 2A)
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: (To be completed if using Table 2A)
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.
Lamp/Lampholder Compatibility			List ANSI-IEC Designated Lamp Base Type				_______	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.
			ANSI-IEC Standardized Lamp?				Yes OR No
			If “Yes”, list ANSI-IEC Lamp Standard Data Sheet Number				_______ OR N/A
Ballast Requirements: (To be completed if using Table 2A)
Electromagnetic and Radio Frequency Interference			Check box if the ballast meets FCC requirements for consumer use:					No documentation required at time of submittal.
End of Life Protection (Required for ballasts with lamps sized T5 & smaller)			Testing requirements met?				Yes OR No	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
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.

SECTION II -- TEST RESULTS (continued): (Complete using average of tested samples)
Fixture Requirements: (To be completed if using Table 2A or Table 2B, unless noted otherwise)
Automatic Daylight Shutoff		Check box if photosensor is integrated into the submitted fixture(s):				Provide applicable sections of fixture manual(s) that demonstrate controls exist for each fixture being submitted
		Check box if photosensor automatically reactivates within 24 hours of a manual override or testing operation:
Motion Control (Table 2B only)		Check box if motion sensor is integrated into the submitted fixture(s):				Provide applicable sections of fixture manual(s) that demonstrate controls exist for each fixture being submitted
		Check box if motion sensor allows automatic shut-off of the lamp within 15 minutes of manual or automatic activation:
		Check box if motion sensor automatically reactivates within 24 hours of a manual override or testing operation:
		Check box if submitted fixture(s) have an indicator that visibly or audibly informs user that sensor is operating properly or has malfunctioned:
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.
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		Check box if the submitted fixtures meet UL safety requirements:				Cover page of a safety test report or a general coverage statement, including evidence of a Rain Test for wet-listed fixtures.
		List for Wet Location?		Yes N/A
		List for Damp Location?		Yes N/A
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 (Table 2A only)?		Yes N/A
		Does the packaging suggest that the consumer select a lamp with a rated lamp life of 10,000 hours or more (Table 2A only)?		Yes N/A
		For all fixtures:
		Does the packaging indicate the minimum starting temperature for the lamp and ballast platform of the fixture (Table 2A only)?		Yes N/A
		For automatic daylight shutoff controls that can be adjusted to operate in full daylight or will not reactivate within 24 hours of a manual override or testing operation, does packaging indicate which settings will result in compliance?		Yes N/A
		For motion controls that can be adjusted such that shut-off will not occur within 15 minutes or will not reactivate within 24 hours of a manual override or testing operation, does packaging indicate which settings will result in compliance (Table 2B only)?		Yes N/A
Decorative LEDs		Do any of the submitted fixtures use decorative LEDs?		Yes OR No		Fixture manufacturer description with the total wattage consumed by all the LEDs, manufacturer warranty; an LED manufacturer specification sheet that shows 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.
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
	Reporting Form (QPI - this document). Refer to SIR “Instructions” Section for						platform)
	further guidance				4.		Attach and email the compiled submittal:
2.	Fill out entire RLF QPI form based on requirements for submittal type (“Lamp						• one (1) QPI form, and
	&/or Ballast Platform,” “Complete Fixture,” or “Both”)						• one (1) RLF SIR form
					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.

February 2006 Version 4.0

EPA Form No. 5900-72