Form 1633confirmproto Confirmed Prototype Test Record

CONFIRMED PROTOTYPE TEST RECORD*

OMB 3041- 0133
16 CFR Part 1633 – Standard for the Flammability (Open Flame) of Mattress Sets

DATE: _____/_____/_____

TEST FACILITY:

Firm Name:______________________ PROTOTYPE ID: ________________________

Name

________________________________________________

Address

________________________________________________
Street

________________________________________________
City

State

TYPE OF TEST ROOM:

ZIP

_____ Configuration A – Open Calorimeter
_____ Configuration B – Room (10ft. x 12ft. x 8ft.)

ROOM CONDITIONS:

Temperature

_____ °C / °F

% Relative Humidity _____

TIME OUT OF CONDITIONING ROOM:

TEST START TIME

___:____ a.m. / p.m.

TEST DATA:

___:____ a.m. / p.m.

Total Heat Release

_______ MJ

(within first 10 minutes)

Peak Heat Release Rate

_______ kW

(within first 30 minutes)

DATE OF TEST:

_______/_______/_______
Month

TEST RESULTS:

Day

Accept ______

Year

Reject ______

I certify that this test was carried out in full accordance with the provisions of the Standard for
the Flammability (Open Flame) of Mattress Sets – 16 C.F.R. Part 1633.
TESTED BY:

Name

Print

Signature

CERTIFIED BY:

________________________________

Name

________________________________

________________________________
Print

Signature

________________________________

*To complete test record requirements under § 1633.11(a) for confirmed prototypes, the information contained herein
must be accompanied by:
(1) a graphic depiction of the peak rate of heat release and the calculated total heat release over time; and
(2) a video or photographs of the testing of the mattress set.
This data sheet may be used in combination with a third-party laboratory test report.