Qualified/Confirme Qualified/Confirmed Prototype Records

QUALIFIED/CONFIRMED PROTOTYPE RECORDS

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

DATE: _____/_____/_____

QUALIFIED/CONFIRMED
PROTOTYPE ID:

Firm Name:________________________

___________________________

SUBORDINATE PROTOTYPES REPRESENTED BY
QUALIFIED/CONFIRMED PROTOTYPE:
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MODELS REPRESENTED BY
QUALIFIED/CONFIRMED PROTOTYPE:
________________________

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1

QUALIFIED/CONFIRMED PROTOTYPE RECORDS

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

DATE: _____/_____/_____

PROTOTYPE ID: ________________________

MANUFACTURING SPECIFICATIONS
DESIGN TYPE:

_____

Smooth

_____

Tufted

_____

Panel Quilt

_____

Pillow Top

_____

Box Top

_____

Euro Top

_____

Single Sided

_____

Double Sided

_____

Other (specify) __________________________

_____

Mattress intended to be used alone

_____

Mattress intended to be sold with foundation(s):

(Check all that apply)

FOUNDATION INFORMATION:

_________________________________________________________
_________________________________________________________
_________________________________________________________
_____

Mattress intended to be sold alone or with foundation(s):
_________________________________________________________
_________________________________________________________
_________________________________________________________

ORDER OF ASSEMBLY FROM SURFACE TO CORE:

DESCRIPTION OF MATTRESS COMPONENT MATERIALS: If a particular material is not used in the prototype,
write “NA” in the space provided.
1. Ticking
Name/Style

________________________________________________________________

Color/Pattern

________________________________________________________________

Construction

________________________________________________________________

Fiber Content

________________________________________________________________

Fabric Weight

________________________________________________________________

Finish Application ________________________________________________________________
FR details (if any) ________________________________________________________________
Supplier Info

________________________________________________________________
Name

________________________________________________________________

Street Address

________________________________________________________________

City

State

2

ZIP

QUALIFIED/CONFIRMED PROTOTYPE RECORDS

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

DATE: _____/_____/_____

PROTOTYPE ID: ________________________

2. Quilted Ticking Components
a. Foam
Name/Style

_________________________________________________________

Thickness

_________________________________________________________

Density

_________________________________________________________

Chemical
Composition

_________________________________________________________

FR details (if any) _________________________________________________________
Supplier Info

_________________________________________________________
Name

_________________________________________________________

Street Address

_________________________________________________________

City

b.

State

ZIP

Fiber-fill
Name/Style

_________________________________________________________

Thickness

_________________________________________________________

Fiber Content

_________________________________________________________

FR details (if any) _________________________________________________________
Supplier Info

_________________________________________________________
Name

_________________________________________________________

Street Address

_________________________________________________________

City

c.

State

ZIP

Barrier
Name/Style

_________________________________________________________

Thickness

_________________________________________________________

Fiber Content

_________________________________________________________

FR details (if any) _________________________________________________________
Supplier Info

_________________________________________________________
Name

_________________________________________________________

Street Address

_________________________________________________________

City

d.

State

ZIP

Backing
Name/Style

_________________________________________________________

Construction

_________________________________________________________

Fiber Content

_________________________________________________________

Fabric Weight

_________________________________________________________

FR details (if any) _________________________________________________________
Supplier Info

_________________________________________________________
Name

_________________________________________________________

Street Address

_________________________________________________________

City

State

3

ZIP

QUALIFIED/CONFIRMED PROTOTYPE RECORDS

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

DATE: _____/_____/_____

e.

PROTOTYPE ID: ________________________

Thread
Name/Style

_________________________________________________________

Color

_________________________________________________________

Fiber Content

_________________________________________________________

Denier

_________________________________________________________

FR details (if any) _________________________________________________________
Supplier Info

_________________________________________________________
Name

_________________________________________________________

Street Address

_________________________________________________________

City

State

ZIP

3. Foam (describe all layers if more than one)
Name/Style

________________________________________________________________

Thickness

________________________________________________________________

Density

________________________________________________________________

Chemical
Composition

________________________________________________________________

FR details (if any) ________________________________________________________________
Supplier Info

________________________________________________________________
Name

________________________________________________________________

Street Address

________________________________________________________________

City

State

ZIP

4. Fiber-fill (if different from fiber in quilted ticking)
Name/Style

________________________________________________________________

Thickness

________________________________________________________________

Fiber Content

________________________________________________________________

FR details (if any) ________________________________________________________________
Supplier Info

________________________________________________________________
Name

________________________________________________________________

Street Address

________________________________________________________________

City

State

ZIP

5. Barrier (if different from fiber in quilted ticking)
Name/Style

________________________________________________________________

Thickness

________________________________________________________________

Fiber Content

________________________________________________________________

FR details (if any) ________________________________________________________________
Supplier Info

________________________________________________________________
Name

________________________________________________________________

Street Address

________________________________________________________________

City

State

4

ZIP

QUALIFIED/CONFIRMED PROTOTYPE RECORDS

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

DATE: _____/_____/_____

PROTOTYPE ID: ________________________

6. Tufting (buttons, laces, threads, yarns, and twine)
Name/Style

________________________________________________________________

Color

________________________________________________________________

Fiber Content

________________________________________________________________

Denier

________________________________________________________________

FR details (if any) ________________________________________________________________
Supplier Info

________________________________________________________________
Name

________________________________________________________________

Street Address

________________________________________________________________

City

State

ZIP

7. Binding Tape
Name/Style

________________________________________________________________

Color

________________________________________________________________

Width

________________________________________________________________

Fiber Content

________________________________________________________________

Construction

________________________________________________________________

FR details (if any) ________________________________________________________________
Supplier Info

________________________________________________________________
Name

________________________________________________________________

Street Address

________________________________________________________________

City

State

ZIP

8. Insulator Pad
Name/Style

________________________________________________________________

Color

________________________________________________________________

Fiber Content

________________________________________________________________

Construction

________________________________________________________________

FR details (if any) ________________________________________________________________
Supplier Info

________________________________________________________________
Name

________________________________________________________________

Street Address

________________________________________________________________

City

State

ZIP

9. No Skid Fabric/Skid Pad
Name/Style

________________________________________________________________

Color

________________________________________________________________

Fiber Content

________________________________________________________________

Construction

________________________________________________________________

FR details (if any) ________________________________________________________________
Supplier Info

________________________________________________________________
Name

________________________________________________________________

Street Address

________________________________________________________________

City

State

5

ZIP

QUALIFIED/CONFIRMED PROTOTYPE RECORDS

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

DATE: _____/_____/_____

PROTOTYPE ID: ________________________

10. Core
Name/Style

________________________________________________________________

Material

________________________________________________________________

Thickness

________________________________________________________________

Construction

________________________________________________________________

FR details (if any) ________________________________________________________________
Supplier Info

________________________________________________________________
Name

________________________________________________________________

Street Address

________________________________________________________________

City

State

ZIP

11. Other
Name/Style

________________________________________________________________

Specifications

________________________________________________________________
________________________________________________________________
________________________________________________________________

FR details (if any) ________________________________________________________________
Supplier Info

________________________________________________________________
Name

________________________________________________________________

Street Address

________________________________________________________________

City

State

ZIP

12. Other
Name/Style

________________________________________________________________

Specifications

________________________________________________________________
________________________________________________________________
________________________________________________________________

FR details (if any) ________________________________________________________________
Supplier Info

________________________________________________________________
Name

________________________________________________________________

Street Address

________________________________________________________________

City

State

ZIP

13. Other
Name/Style

________________________________________________________________

Specifications

________________________________________________________________
________________________________________________________________
________________________________________________________________

FR details (if any) ________________________________________________________________
Supplier Info

________________________________________________________________
Name

________________________________________________________________

Street Address

________________________________________________________________

City

State

6

ZIP

QUALIFIED/CONFIRMED PROTOTYPE RECORDS

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

DATE: _____/_____/_____

PROTOTYPE ID: ________________________

DESCRIPTION OF FOUNDATION COMPONENT MATERIALS (IF ANY):
1. Ticking
Name/Style

________________________________________________________________

Color/Pattern

________________________________________________________________

Construction

________________________________________________________________

Fiber Content

________________________________________________________________

Fabric Weight

________________________________________________________________

Finish Application ________________________________________________________________
FR details (if any) ________________________________________________________________
Supplier Info

________________________________________________________________
Name

________________________________________________________________

Street Address

________________________________________________________________

City

State

ZIP

2. Frame
Name/Style

________________________________________________________________

Material

________________________________________________________________

Depth

________________________________________________________________

FR details (if any) ________________________________________________________________
Supplier Info

________________________________________________________________
Name

________________________________________________________________

Street Address

________________________________________________________________

City

State

ZIP

3. Other
Name/Style

________________________________________________________________

Specifications

________________________________________________________________
________________________________________________________________

FR details (if any) ________________________________________________________________
Supplier Info

________________________________________________________________
Name

________________________________________________________________

Street Address

________________________________________________________________

City

State

ZIP

4. Other
Name/Style

________________________________________________________________

Specifications

________________________________________________________________
________________________________________________________________

FR details (if any) ________________________________________________________________
Supplier Info

________________________________________________________________
Name

________________________________________________________________

Street Address

________________________________________________________________

City

State

7

ZIP