5900-171 Qualified Product Information Form for ENERGY STAR Batte

OMB Control No. 2060-0528

Approval expires 03/31/2011

United States

ENVIRONMENTAL PROTECTION AGENCY
Washington, DC 20460

Qualified Product Information for ENERGY STAR® Battery Charging Systems Part 1
ENERGY STAR product information form for use by battery charging system (BCS)
partners (Companies that have joined ENERGY STAR for battery charging systems
by signing a Partnership Agreement)
Manufacturer Name:
Brand Name:
Model Number:
Model Name:
Contact Information
Contact Name for this product:
Contact Phone:
Contact Email Address:
Contact Fax:
Manufacture Information
Initial Date of Manufacture:
Date No Longer Manufactured:
Date Available on the Market:
Available Markets
To what major markets is this product sold?
(Check all that apply.)

Labeling Information
Indicate where ENERGY STAR label appears.
(Check all that apply.)
On product advertising / promotional
materials?

Australia/New Zealand?
Canada?

On product packaging/box?

European Union?

In product literature?

Japan?

On your Internet site?

Mexico?
Taiwan?
United States?
Other?
Testing Information
Date Tested:
Self-Tested? (Y/N)

Yes

No

If not Self-Tested, please provide the following information regarding the Testing Facility and Test Technician.

Test Facility Name:
Test Facility Country:
Test Technician First Name:
Test Technician Last Name:
Test Technician Email:
The public reporting and recordkeeping burden for this collection of information is estimated to average 4.85 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.

EPA Form No. 5900-171

Submit completed form to ENERGY STAR at [email protected]
Page 1 of 3

OMB Control No. 2060-0528

Approval expires 03/31/2011

Qualified Product Information for ENERGY STAR® Battery Charging

Systems - Part 2

ENERGY STAR product information form for use by battery charging system (BCS)
partners (Companies that have joined ENERGY STAR for battery charging systems
by signing a Partnership Agreement)

Product Details
1. End-Use Product Type (e.g., power tool, appliance, personal care
product, yard care product, universal battery charger):
2. Battery Chemistry (e.g., NiCad, NiMh, Li Ion):
3. Indicate battery charger type (Refer to Section 1.B of ENERGY STAR BCS Eligibility Criteria
for definitions and check all that apply):

a la carte

multi-voltage

multi-port

stand-alone

batch
If product is not packaged with a battery or product (e.g., a stand-alone a la carte charger), please
attach a list of all batteries/products designed for use with this product including part number, battery
chemistry, nominal voltage and rated battery capacity.
Nameplate Specification
Nameplate Input Voltage (V):
Nameplate Input Frequency (Hz):
Nameplate Input Current (Amps):
Nameplate Input Power (W):
If input power is not listed on the nameplate, refer to Section 1.B of ENERGY STAR BCS Eligibility
Criteria for the appropriate calculation.
Testing Details
1. Were 3 randomly selected units of the same model tested?
2. Did all 3 units that were tested at each input voltage meet the
qualification criteria?

Yes

No

Yes

No

3. Please list the battery types used for testing. Chargers that are both a la carte and multi
voltage must be tested using at least three currently produced batteries identified/listed as
usable with the unit, including the batteries with the highest and lowest nominal battery
energy. Multi-port chargers using identical batteries need only list each battery type once.
Attach full test results as indicated in BCS Test Methodology.
# 1 Part Number:
Nominal Voltage (V):
Measured Battery Energy (Wh):
# 2 Part Number:
Nominal Voltage (V):
Measured Battery Energy (Wh):

Submit completed form to ENERGY STAR at [email protected]
Page 2 of 3

EPA Form No. 5900-171

OMB Control No. 2060-0528

Approval expires 03/31/2011

# 3 Part Number:
Nominal Voltage (V):
Measured Battery Energy (Wh):
4. Reference Voltage for Qualification (Nominal battery voltage,
except for a la carte multi-voltage and batch chargers. See
ENERGY STAR BCS Test Methodology for further explanation):
5. Was the abbreviated method used for either the measurement of
Maintenance or Standby modes? If yes, please submit a
written statement indicating that the unit under test qualifies for
the abbreviated test methodology.

Yes

No

Test Results
Provide average test results for three randomly chosen units of the same model. For a la carte
models, be sure to submit the average value for all batteries/products tested. In addition, test results
are required at 1, 2, or 3 voltage/frequency combinations, based on the market(s) in which the model
will be sold and promoted as ENERGY STAR qualified. Please refer to Section 4.C of the BCS
Eligibility Criteria for additional details.
Test Results - 115 Volts ac 60 Hz
Average battery maintenance accumulated energy over 36 hours (wh):

Average standby accumulated energy over 12 hours (wh):

Total Nonactive Energy:

Power Factor:

Nonactive Energy Ratio:

Test Results - 230 Volts ac 50 Hz
Average battery maintenance accumulated energy over 36 hours (wh):

Average standby accumulated energy over 12 hours (wh):

Total Nonactive Energy:

Power Factor:

Nonactive Energy Ratio:

Test Results - 100 Volts ac 50/60 Hz
Average battery maintenance accumulated energy over 36 hours (wh):

Average standby accumulated energy over 12 hours (wh):

Total Nonactive Energy:

Power Factor:

Nonactive Energy Ratio:

Submit completed form to ENERGY STAR at [email protected]
Page 3 of 3

EPA Form No. 5900-171