Form 5900-252 Failure Report

						Expiration Date: 1/31/2022
					OMB Control No. 2060-0528
	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 ENERGY STAR manufacturing partner name(s) and model number(s). CBs must complete and submit this document along with the laboratory test report and any supporting documentation. Example subject line: "FAILURE ENERGY STAR Manufacturing Partner Name 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:
				Year Model Was Selected for Verification 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:			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:
	This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2060-0528). Responses to this collection of information are voluntary (Section103(g) of the Clean Air Act). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to 6.3 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 to the Regulatory Support Division Director, U.S. Environmental Protection Agency (2821T), 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.
	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 a verification testing failure, please include the verification testing results, ENERGY STAR specification requirement(s) for the performance criteria that the product failed, and initial testing results.
	Section IV: Additional Model Numbers
	List the identifying information for any private label models, family models, or other related models qualified on the same basis as the product that failed testing. Please attach additional pages, if necessary.
	ENERGY STAR Manufacturing Partner:		Brand Name:	Model Name:	Model Number	ENERGY STAR Model Identifier:
	United States ENVIRONMENTAL PROTECTION AGENCY Washington, DC 20460 Office of Atmospheric Programs
	EPA Form No. 5900-252