6100-09 Annual Reporting Form - Retail/Distributor

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Retailer and Distributor - Annual Reporting

General Information

Retailer/Distributor Name on Partnership Agreement * Please select...

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Contact Name(s)
Please provide U.S. contacts if possible. This information is for internal use only, WaterSense will not share contact
information.

Name *
Email *
Telephone *
Contact Type * Please select...

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Primary Contact
Reporting
Technical

To select multiple options: - Using Windows, hold Ctrl key and select

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multiple options with mouse. - Using a Mac, hold Command key and select multiple options with mouse.
Contact Update? * Please select...
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Name
Email
Telephone
Contact Type Please select...
Primary Contact
Reporting
Technical

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Contact Update? Please select...

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Please update your interests and preferences to receive more specific communications from WaterSense.

WaterSense Labeled Product Availability and Program Feedback
Information on WaterSense's impact on the marketplace is vital to the continued success of the program. Please
provide data on product availability and promotion.
1a. Are you promoting your WaterSense labeled products to consumers or other stakeholders? * 
 Yes
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 No
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1b. Please estimate the number of customers reached in 2012 (e.g., through circulars, via the Web, store
visitors, etc.) *
Please enter a number without commas.
1c. Please indicate how you are promoting your WaterSense labeled products. *
Please select...
 To select multiple options: - Using Windows, hold
In-store promotions, such as displays and other signage
Ads and circulars
Brochures, other marketing materials

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Ctrl key and select multiple options with mouse. - Using a Mac, hold Command key and select multiple options
with mouse.
Other description
1d. If yes, are you working with other types of partners (e.g., utilities or manufacturers) to promote
WaterSense labeled products to consumers? *
 Yes 
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

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 No
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Please elaborate on your efforts and include the specific partners with whom you're working. *

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2. Did your company participate in any WaterSense promotional campaigns last year? *
Please select...
 To select multiple options: - Using Windows, hold Ctrl key and select
Fix a Leak Week 2012
We're for Water
Peak water season outreach

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multiple options with mouse. - Using a Mac, hold Command key and select multiple options with mouse.
Other description *
Please elaborate on your company's participation *

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3. On a scale of 1 to 5 (5 = most valuable), how valuable do you find the WaterSense program? *
Please select... 

How has the WaterSense label added value? *

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4. On a scale of 1 to 5 (5 = most valuable), how valuable do you find the WaterSense partner website? *
Please select... 

5. In the past year, how often have you visited the WaterSense partner website? * Please select...
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6. By submitting both your online and hard copy annual reporting forms, you will be eligible to apply for
a 2013 WaterSense Partner of the Year award. WaterSense encourages all partners to apply regardless
of company size. Are you interested in applying for an award this year? *
 Yes 
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
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 No
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Help us improve the awards program by telling us why you're not interested in applying for an award. *
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Please go to the awards page for application materials and instructions. Award application materials will be
available on the WaterSense partner website by February 1. WaterSense encourages all retailer/distributor
partners who actively promoted WaterSense labeled products in 2012 to apply regardless of company size.
7. Please provide suggestions for improving the WaterSense program (e.g., general tools/materials,
webinar topics, communications, Helpline, websites, etc.) *
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On the following page, you will be asked to review your responses. You must select "confirm" at the bottom
of the following page to submit the online portion of your Annual Reporting Form to WaterSense. You
will then be automatically directed to instructions for accessing a PDF form to submit your product sales data in
accordance with our confidential business information procedures.

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Please note that you may need to try different printer settings or print as a PDF to print the full online report for
your records. We apologize for any inconvenience.

Your Annual Reporting Form will not be complete until WaterSense receives both your online and hard
copy reporting forms.
Need assistance with this form?

OMB Control Number 2040-0272
Approval Expires 06/30/2013
EPA Form Number 6100-09. The public reporting and record keeping burden for this collection of
information is estimated to average three 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 Avenue, NW,
Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the
completed form to this address.