5900-254 Lighting Disputable Partner Response Form

Partner Response Form
Instructions
1. Yellow fields are required. If any are blank, EPA will reject your submittal. 2. If you do not include a representative signature at the bottom of this form, EPA will reject your submittal. 3. Check Option A or Option B below, and complete all of the corresponding sections.
• Option A, Submitting Product Control Measures: Complete Sections I, II, III, IV, VI, and VII. Check here for Option A: • Option B, Disputing the pending disqualification: Complete Sections I, II,V, VI and VII. Check here for Option B:
4. Click on each field for additional instructions.
Save your completed form as "Testing Failure_[Company Name]_[EPA Case Number]" and submit it to [email protected]. EPA will review your submittal, and notify you once the form is approved or if additional information is necessary.
Section I: Product and Shipping Information (Option A or B)
Partner Name (company):			Date Last Manufactured:
EPA Case Number (from EPA letter):			Date of Last Sales Shipment (labeled units):
Original Equipment Manufacturer (OEM):			Recipient of Last Sales Shipment (labeled units):
Test Failure Notification Date:			Destination of Last Sales Shipment (labeled units):
Tested Unit's Brand Name:			Units Shipped in Last 6 months (labeled units):
Model's ENERGY STAR Product Category:			Total Units Manufactured (labeled units):
Disqualified Model Number (from EPA letter):			Is the model promoted by an energy efficiency program and/or utility? (If yes, provide name[s])
Section II: Contact Information (Option A or B)
Point of Contact at Your Company:			Original Equipment Manufacturer (OEM):
Title:			OEM Contact:
Email:			Title:
Phone:			Email:
Additional Contacts?			Phone:
Name (Email)
Section III: Certification of Product Control Measures (PCM) (Option A, Part I)
Only complete this section if submitting product control measures. If disputing the pending disqualification, proceed to Section IV.
For the model numbers in Sections I and V, the company named in the Partner Name field of Section I is undertaking the following measures. Note: If you seek to deviate from the proposed measures after EPA has approved them, you must notify EPA prior to making any changes.
1) Inform your distribution chain that the model(s) is/are not ENERGY STAR certified: EPA requires that you notify all downstream parties to whom you directly sold the model(s) as ENERGY STAR certified in the last two years, including but not limited to all distributors, online and in-store retailers, consumers, and other affected organizations (e.g., utilities), that the model(s) is/are no longer ENERGY STAR certified. Specifically, the following statement must be included in all communications: "This product failed verification testing and has been disqualified from ENERGY STAR." Use the table below to submit a list of these entities. If you need additional rows, submit with this form a supplementary document listing the additional organizations contacted. Enter "N/A" for any unused rows.
Organization Name:		Organization Type:		Proposed or Actual Completion Date:
e.g., Big Box Store		e.g., National Retailer		e.g., 3/15/12
If the distribution chain you've listed above includes one or more of the product retailers identified in EPA's testing failure email to your organization, you must include the EPA-provided contact(s)for that/those retailer(s)as part of your downstream notice that the model(s) is/are no longer ENERGY STAR certified. EPA expects that you have or will contact the applicable contact(s) by the completion date(s) listed above.					I agree to the statement at left
2) Remove the ENERGY STAR mark from all:		Applicable?	Proposed or Actual Completion Date:	Number of Units:
	a) Affected Units: (within your control)
		Applicable?	Proposed or Actual Completion Date:	Number of Units:
	b) Unit Packaging: (within your control)
		Applicable?	Proposed or Actual Completion Date:	URL of Modified Website:
	c) Website References to Model(s):
		Applicable?	Proposed or Actual Completion Date:	Example of Modified Marketing Material:
	d) Marketing Materials: (e.g., spec sheets)
Section IV: Quality Assurance Requirements (Option A, Part II)
Due to the verification testing failure of the OEM model for this product, additional control measures are required. You will be required to provide to EPA quality assurance documentation consistent with the quality management system (QMS) that your company and/or the OEM has implemented. More information regarding this required action may be found at www.energystar.gov/lightingqa. Your submission of quality assurance documentation should be made using the standard form available at www.energystar.gov/lightingqa. Please submit your quality assurance documentation to [email protected] within 30 days of submitting this Partner Response Form. Please include the appropriate case number in the subject line when submitting your quality assurance documentation. Additionally, EPA requires that another one of your organization's products, from the same OEM, undergo off-the-shelf, third-party testing. You will receive a separate notice from EPA regarding this required testing, which will identify the product selected and include instructions for testing.					By checking the box below, you agree to take the actions described at left by the required deadline.
Section V: Dispute Disqualification (Option B)
In your e-mail response to EPA, attach any technical information that supports your dispute of this disqualification. EPA will conduct a technical review of all dispute information submitted and determine whether to maintain the product(s) as certified.
Basis of Dispute:
EPA Determination: (For EPA use only)
Section VI: Additional Model Numbers (Option A or B)
Use this section for affected family models. Fill out a new form for any models requiring different actions or estimated completion dates from those entered in Section III.
Additional Model #:		Units Shipped in Last 6 Months:		Date of Last Sales Shipment:
Additional Model #:		Units Shipped in Last 6 Months:		Date of Last Sales Shipment:
Additional Model #:		Units Shipped in Last 6 Months:		Date of Last Sales Shipment:
Additional Model #:		Units Shipped in Last 6 Months:		Date of Last Sales Shipment:
Section VII: Additional Comments (optional)
Use this section to provide EPA with relevant information not included elsewhere in this form.
Representative Signature
As a representative of this company, I hereby certify on its behalf as to the actions taken or to be taken by it, as described above in this form. Failure to implement these actions as indicated, or to inaccurately certify as completed, may result in partnership suspension or termination, or the loss of other ENERGY STAR program benefits. I understand that intentionally submitting false information to the U.S. government is a criminal violation of the False Statements Act, Title 18 U.S.C. section 1001.
	Name (First & Last)		Date	I agree to the above statement
OMB Control No. 2060-0528