5900-252 ENERGY STAR Failure Report

	ENERGY STAR® Failure Report
	Instructions
	Certification bodies shall report verification testing failures within 2 business days of observation of the failure to [email protected] using the subject line "FAILURE" followed by the manufacturer name(s) and model number(s). Example subject line: "FAILURE Manufacturer X Model #######"
	Section I: Product and Shipping Information
	Name of Certification Body:			Date Model Available on Market:
	Product Specification:			Type of Product Failure:
	ENERGY STAR Manufacturing Partner:			Date Certification Body Determined Failure:
	Original Equipment Manufacturer (OEM): (if Partner listed is not OEM)			Date(s) of Initial Testing:
	OEM Model Number: (if Partner listed is not OEM)			Name of Lab that performed Certification Testing:
	Is OEM Model qualified? (under OEM's brand/org name)			Lab EPA-issued Org ID:
	Brand Name:			Verification Testing-Date(s) for single unit testing or spot-check test:
	Certified Model Name:			Verification Testing-Date(s) for remaining samples where multiple test sample (approach two) is used:
	Certified Model Number:			Name of Lab that performed Verification Testing:
	ENERGY STAR Model Identifier: (applicable for products submitted via XML only)			Lab EPA-issued Org ID:
	Product Type:			Where unit was obtained:
	Tested Model Name:			If product was obtained off-the-line or other; provide reason
	Tested Model Number:			Tested Model Date(s) of Manufacturer: (if available)
	Tested Serial Number(s):			Date(s) Unit was Obtained:
	Section II: Contact Information
	Point of Contact at the Certification Body:			Partner Contact:
	Job Title:			Job Title:
	Email:			Email:
	Phone Number:			Phone Number:
	Additional Contacts?
	Name (e-mail)
	Section III: Verification Testing Results
	Describe all the relevant testing results. If reporting verification testing failure, please include the verification testing results and initial testing results.
	Section IV: Additional Model Numbers
	List any private label models, family model names/numbers/or other identifying information of any additional models qualified on the same basis as the product that failed testing. Please attach additional pages, if necessary.
	Additional Models:			ENERGY STAR Manufacturing Partner:
	Additional Models:			ENERGY STAR Manufacturing Partner:
	Additional Models:			ENERGY STAR Manufacturing Partner:
	Additional Models:			ENERGY STAR Manufacturing Partner:
	Additional Models:			ENERGY STAR Manufacturing Partner:
	Additional Models:			ENERGY STAR Manufacturing Partner:
	Additional Models:			ENERGY STAR Manufacturing Partner:
	Additional Models:			ENERGY STAR Manufacturing Partner:
	Last updated March 11, 2013
	United States ENVIRONMENTAL PROTECTION AGENCY Washington, DC 20460 Office of Atmospheric Programs
	The public reporting and recordkeeping burden for this collection of information is estimated to average 11 hours per response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.