DOE New Traffic Signal Ped Modules

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Overview

Certification
Input
Product Description
Instructions

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Sheet 1: Certification

Traffic Signal Modules and Pedestrian Modules	Product Type:	Traffic Signal Modules and Pedestrian Modules	Version 4.1
4.1
		Status of This Certification Sheet	No Data
		Overall Status of Template	No Data
	Submitter Information
	I am a(n) (check one only):
			Please enter required data
	The third-party representative includes industry organizations submitting on behalf of their members, foreign manufacturers who do not import and are submitting on behalf of their importers, private labelers submitting on behalf of an importer or domestic manufacturers, third-party testing organizations submitting on behalf of a manufacturer, etc.
	Submitter Information (Required for all submissions):
	Company Name:		Please enter required data
	Company Address:		Please enter required data
	Contact Name:		Please enter required data
	Contact Telephone Number:		Please enter required data
	Contact Fax Number:		Please enter required data
	Contact email address:		Please enter required data
	For importers, the U.S. Customs and Border Protection importer identification number (OPTIONAL):
	Third Party-Representatives (If Submitter is not a Third-Party Representative, skip to Certification
	If the submitter is a third-party representative, provide the following information on each company on whose behalf you are certifying. Note: Please complete an additional template if you are certifying on behalf of more than five companies.
	If you are a Third-Party Representative, for how many companies on whose behalf are you certifying? (Maximum of 5)
	1. Company Name:
	Company Address:
	Responsible Person at Company:
	Telephone Number:
	Fax Number:
	Email Address:
	Select all that apply (at least one):
	For Importer - U.S. Customs and Border Protection importer identification number (OPTIONAL):
	For Private Labeler - Provide all of the brand name(s):
	2. Company Name:
	Company Address:
	Responsible Person at Company:
	Telephone Number:
	Fax Number:
	Email Address:
	Select all that apply (at least one):
	For Importer - U.S. Customs and Border Protection importer identification number (OPTIONAL):
	For Private Labeler - Provide all of the brand name(s):
	3. Company Name:
	Company Address:
	Responsible Person at Company:
	Telephone Number:
	Fax Number:
	Email Address:
	Select all that apply (at least one):
	For Importer - U.S. Customs and Border Protection importer identification number (OPTIONAL):
	For Private Labeler - Provide all of the brand name(s):
	4. Company Name:
	Company Address:
	Responsible Person at Company:
	Telephone Number:
	Fax Number:
	Email Address:
	Select all that apply (at least one):
	For Importer - U.S. Customs and Border Protection importer identification number (OPTIONAL):
	For Private Labeler - Provide all of the brand name(s):
	5. Company Name:
	Company Address:
	Responsible Person at Company:
	Telephone Number:
	Fax Number:
	Email Address:
	Select all that apply (at least one):
	For Importer - U.S. Customs and Border Protection importer identification number (OPTIONAL):
	For Private Labeler - Provide all of the brand name(s):
	Certification
	Compliance Statement
	SELECT SUBMITTER TYPE AT THE TOP OF THIS WORKSHEET
	Type your full name to signify compliance (required):		Please enter required data
	Enter your email address (required):		Please enter required data
	Date (MM/DD/YYYY) (required):		Please enter required data
	OMB Control Number: 1910-1400
	OMB Form Number: None
	Paperwork Reduction Act Statement
	OMB Burden Disclosure Statement
	This data is being collected for manufacturers to certify compliance to DOE's energy conservation, water conservation, or design standards. The data you supply will be used by the Department to monitor compliance with the energy conservation, water conservation, and design standards and testing requirements for the consumer products and commercial and industrial equipment mandated by the Energy Policy and Conservation Act, as amended. Public reporting burden for this collection of information is estimated to average 20 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Office of the Chief Information Officer, Records Management Division, IM-23, Paperwork Reduction Project (1910-1400), U.S. Department of Energy, 1000 Independence Ave SW, Washington, DC, 20585-1290; and to the Office of Management and Budget (OMB), OIRA, Paperwork Reduction Project (1910-1400), Washington, DC 20503. Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB control number. Submission of this data is mandatory.

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Sheet 2: Input

Traffic Signal Modules and Pedestrian Modules	Product Type:		Traffic Signal Modules and Pedestrian Modules					Version 4.1
4.1
	Status of This Input Sheet		No Data		Overall Status of Template		No Data
Certification Report
· Please enter your data in the columns shaded in gray below, using a separate line for each model. · Click on the column heading for instructions on how to complete cells in that column. · Cells highlighted in yellow indicate an "Error." "Error" means that information is missing or there is an issue with the entry. · If the "Status" for a row is "Error," you can see an explanation in the columns to the right of the Status column. · Reports submitted with errors cannot be processed and will be returned for resubmission.																		The cells below provide an explanation for "Errors".			The cells below provide an explanation for "Errors".			The cells below provide an explanation for "Errors".			The cells below provide an explanation for "Errors".		The cells below provide an explanation for "Errors".			The cells below provide an explanation for "Errors".
Line No.	Status	Manu-facturer	For Third-Party Representatives, Company Number From Certification Sheet	Brand Name(s)	Basic Model Number	Individual Model Number Covered by Basic Model	Action	Product Class	Explanation of 'Other' Product Class	Sample Size (Number of Units Tested)	Is the Certification for this Basic Model Based on a Waiver of DOE's Test Procedure Requirements?	Date of Test Procedure Waiver, if Applicable	Is the Certification based upon any Exception Relief from an Applicable Standard by DOE's Office of Hearing and Appeals?	Date of Exception Relief, if Applicable	Maximum Wattage at 74 Degrees C (watts)	Nominal Wattage at 25 Degrees C (watts)		Manu-facturer Status	For Third-Party Representatives, Company Number From Certification Sheet Status	Brand Name(s) Status	Basic Model Number Status	Individual Model Number Covered by Basic Model Status	Action Status	Product Class Status	Explanation of 'Other' Product Class Status	Sample Size (Number of Units Tested) Status	Is the Certification for this Basic Model Based on a Waiver of DOE's Test Procedure Requirements? Status	Date of Test Procedure Waiver, if Applicable Status	Is the Certification based upon any Exception Relief from an Applicable Standard by DOE's Office of Hearing and Appeals? Status	Date of Exception Relief, if Applicable Status	Maximum Wattage at 74 Degrees C (watts) Status	Nominal Wattage at 25 Degrees C (watts) Status	Status
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Sheet 3: Product Description

The following is a description of each product class:
Product Class	Product Class Description
	Traffic Signal Module Type
1	12" Red Ball
2	8" Red Ball
3	12" Red Arrow
4	12" Green Ball
5	8" Green Ball
6	12" Green Arrow
	Pedestrian Module Type
7	Combination Walking Man/Hand
8	Walking Man
9	Orange Hand
Other	Other traffic signal modules or pedestrian modules of a type not listed above (if you enter "Other", you must provide a rationale in the 'Explanation of "Other" Product Class' column on the "Input" sheet).

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Sheet 4: Instructions

Traffic Signal Modules and Pedestrian Modules

4.1