5900-254 Partner Response Form Lighting

					OMB Control No. 2060-0528
					Expiration Date: 1/31/2022
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. Select 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 & VII. Check here if selecting Option A: • Option B, Disputing the pending disqualification: Complete Sections I, II,V, VI & VII. Check here if selecting 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)
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 1.5 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 III: Certification of Product Control Measures (PCM) (Option A)
Only complete this section if submitting product control measures. If disputing the pending disqualification, proceed to Section V.
For the model numbers in Sections I and VI, 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 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
CFL and ILL products only: 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. By checking the box at right, you indicate you have or will contact the applicable contact(s) by the completion date(s) listed above.
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)
Complete this section if disputing the pending disqualification.
If you wish to dispute the test results, you must identify all grounds for dispute using this form. EPA will conduct a technical review of all dispute information submitted by the date specified in the testing failure letter you received, and determine whether to maintain the product(s) as certified. Please note that all bases for disputes must be raised within the comment period in order for EPA to consider that information. All comments should be included in the dispute section of the partner response form linked above, and additional attachments may be included with that submittal. All partners submitting a dispute may request a conference call with EPA to discuss the testing failure and basis for testing dispute. Check here if you would like to schedule a conference call with EPA to discuss your submittal:
Basis of Dispute:
EPA Determination: (For EPA use only)
Section VI, Part 1: Additional Model Numbers (Option A or B)
If submitting for windows, doors, and skylights products, proceed directly to Section V, Part 2
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 VI, Part 2: Affected Product Options (Option A or B)
Complete this section only if submitting for windows, doors, and skylights products
Use this section to identify all affected product options within the product line of the model number entered in Section I.
Identify affected product options of failed model(s) List the National Fenestration Rating Council (NFRC) Certified Products Directory (CPD) number for any product options qualified on the same basis as the product that failed testing. For example, affected product options may be grouped with or otherwise share components or other product features with the product that failed testing, and as a result of the issue(s) identified during verification testing, the affected product options would also fail to meet the ENERGY STAR requirements. Any affected product options you elect to identify below will need to be reviewed and confirmed by NFRC prior to EPA review of your submittal. Please include with your response a written confirmation letter from an NFRC representative. If you need additional rows, submit with this form a supplementary document listing the additional affected product options. Enter "N/A" for any unused rows. If no additional product options are affected by this failure, provide an explanation in Section VI.
Product Line Number:		CPD # of Affected Product Option:		Explanation: (optional)
Section VII (optional): Additional Comments (Option A or B)
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. 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
EPA Form No: 5900-254