Qualified Prototyp Qualified Prototype Test Record

QUALIFIED 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

TYPE OF TEST ROOM:

State

ZIP

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

TEST 1
Room Conditions
Temperature
_____
% Relative Humidity _____

TEST 3

TEST 2
Room Conditions
Temperature
_____
% Relative Humidity _____

°C / °F

°C / °F

Room Conditions
Temperature
_____
% Relative Humidity _____

°C / °F

Time Out of Conditioning Room
___:____ a.m. / p.m.

Time Out of Conditioning Room
___:____ a.m. / p.m.

Time Out of Conditioning Room
___:____ a.m. / p.m.

Test Start Time
___:____ a.m. / p.m.

Test Start Time
___:____ a.m. / p.m.

Test Start Time
___:____ a.m. / p.m.

Total Heat Release

Total Heat Release

Total Heat Release

(within first 10 minutes)

(within first 10 minutes)

(within first 10 minutes)

_______ MJ

_______ MJ

_______ MJ

Peak Heat Release Rate

Peak Heat Release Rate

(within first 30 minutes)

(within first 30 minutes)

_______ kW

Peak Heat Release Rate
(within first 30 minutes)

_______ kW

_______ kW

Date of Test

Date of Test

Date of Test

____/____/____

____/____/____

____/____/___

TEST RESULTS:

Accept ______

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 qualified 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