Qualified/Confirme Qualified/Confirmed Prototype QA Records

QUALIFIED/CONFIRMED PROTOTYPE QA RECORDS OMB 3041-0133
16 CFR Part 1633 – Standard for the Flammability (Open Flame) of Mattress Sets
DATE: _____/_____/_____ Firm Name: ______________________ PROTOTYPE ID: ________________________

PRODUCTION LOTS REPRESENTED BY QUALIFIED/CONFIRMED PROTOTYPE
LOT NUMBER

START DATE

STOP DATE

QUANTITY

To complete test record requirements under § 1633.11(d) for qualified/confirmed prototypes, the
information contained herein must be accompanied by:
(1) a written copy of the manufacturer’s quality assurance procedures;
(2) records of any production tests performed, to include an assigned production lot
identification number and the identification number of the qualified/confirmed prototype
associated with the specimen tested; and
(3) component, material and assembly records, to include detailed records of technical
evaluations of components and materials and/or methods of assembly.