Form 5900-77 Qualified Product Information Form for Room Air Cleaners

OMB Control No. 2060-0528

Approval Expires XX/XX/XX

United States

ENVIRONMENTAL PROTECTION AGENCY

Washington, DC 20460

Qualified Product Information Form for Room Air Cleaners

Office of Atmospheric Programs

Energy Star^® product information form for use by Energy Star room air cleaner partners (Companies who have joined Energy Star for room air cleaners by signing a 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 room air cleaners.

Company Name: Product Contact Information

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

Name:

Tel:

Fax:

Email:

I.Product Information: A room air cleaner model must produce at least 50 CADR for Dust to be considered for ENERGY STAR. Please use a separate form for each individual air cleaner model. (Air cleaner models that are derivatives of a basic model may be listed on the same form.)

Manufacturer Name	Brand/Model Name	Model Number	Dust CADR	Tobacco Smoke CADR	Pollen CADR	Total Energy Consumption (Watts)	Dust CADR/Watt

Date Available on Market:

Tested By (Laboratory Name or Self-Tested): Date Tested:

II.Standby Power: Standby power for operation of secondary consumer features must be measured and reported in accordance with the Test Procedure provided in Section 4 of the room air cleaner specification.

Does this Model Use Standby Power? Yes No

If answered “yes” to above question;

Total Measured Standby Power: Watts Date Tested:

III.UL Safety Requirements: Models that emit ozone as a byproduct of air cleaning must be in accordance with UL Standard 867.

Meets UL Safety Standard 867: Yes No UL File Number:

IV.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 Room Air Cleaners. These requirements include:

 On top/front of product  In product literature  On partner Web site

In addition to the ENERGY STAR mark, consumer education information and disclaimer language must be placed:

 On product packaging  Within instruction manual  On partner Web site

If answer to any of the above is “no”, please explain:

V.Power Supply: EPA is considering the collection of internal power supply data associated with room air cleaners at a future time following research and discussion with industry stakeholders.

VI.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  China

VII.Product Submittal Procedure: Please submit the completed Qualified Product Information form via standard mail/Fed Ex/Fax/Email to:

ENERGY STAR for Room Air Cleaners

ICF International

1725 Eye Street, NW, Suite 1000

Washington, DC 20006

Fax: (202) 862-1144

Email: [email protected]

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 Room Air Cleaners

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

EPA Form No. 5900-77