DOE F 220.28 Other Than Swich Selectable and Adaptive Single Volatge

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Overview

Certification
Headers
Product Group Code

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Sheet 1: Certification

OMB Control Number: 1910-1400 (Expiration Date: XXXXXX XX, XXXX)

Version 5.x

DOE F 220.28

External Power Supplies Other Than Switch-Selectable and Adaptive Single-Voltage External Power Supplies

Product Type:

External Power Supplies Other Than Switch-Selectable and Adaptive Single-Voltage External Power Supplies

Status of This Certification Sheet

No Data

5.x

Overall Status of Template

No Data

Click here for instructions for completing this form

Each Importer and U.S. Manufacturer is legally required to certify the compliance of the products it imports, produces, assembles or manufactures. This party is the "Certifier" on this form. This certification may be submitted by the Importer or U.S. manufacturer or by a Third Party Representative. This party is the "Submitter" on this form.

Certifier - Party Legally Obligated to Certify Compliance

Submitter - Party Submitting This Report

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The party submitting this report is (select one only):

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Certifier Contact Information

Third Party Representative Contact Information, if Applicable

Full Legal Name of Individual

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Full Legal Name of Individual

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Full Legal Name of Company

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Full Legal Name of Company

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Complete Company Mailing Address

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Complete Company Mailing Address

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Phone Number

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Phone Number

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Email Address

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Email Address

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Note: Importers and U.S. manufacturers of external power supplies that are exempt from energy conservation standards pursuant to 10 CFR Part 430.32(w)(2) must, annually no later than September 1st, submit a report providing the total number of exempt external power supplies sold as spare and service parts, if the total exceeds 1,000 units across all models. A separate template for this mandatory report may be found at https://www.regulations.doe.gov/ccms/templates.

Compliance Statement

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Submitter Signature (Type your Full Legal Name)

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Date (MM/DD/YYYY)

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OMB Control Number: 1910-1400 (Expiration Date: XXXXXX XX, XXXX)

Paperwork Reduction Act Statement

OMB Burden Disclosure Statement

This data is being collected for manufacturers to certify compliance to DOE's energy conservation, water conservation, or design standards. The data you supply will be used by the Department to monitor compliance with the energy conservation, water conservation, and design standards and testing requirements for the consumer products and commercial and industrial equipment mandated by the Energy Policy and Conservation Act, as amended. Public reporting burden for this collection of information is estimated to average 35 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Office of the Chief Information Officer, Records Management Division, IM-23, Paperwork Reduction Project (1910-1400), U.S. Department of Energy, 1000 Independence Ave SW, Washington, DC, 20585-1290; and to the Office of Management and Budget (OMB), OIRA, Paperwork Reduction Project (1910-1400), Washington, DC 20503. Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB control number. Submission of this data is mandatory.

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Sheet 2: Headers

External Power Supplies Other Than Switch-Selectable and Adaptive Single-Voltage External Power Supplies - v5.x

Column Headers:

Status

Manufacturer

Brand Name(s)

Basic Model Number

Individual Model Number Covered by Basic Model

Action

Product Group Code

Sample Size (Number of Units Tested)

Is the Certification for this Basic Model Based on a Waiver of DOE's Test Procedure Requirements?

Date of Test Procedure Waiver, if Applicable

Is the Certification based upon any Exception Relief from an Applicable Standard by DOE's Office of Hearing and Appeals?

Date of Exception Relief, if Applicable

Is this an AC-to-AC EPS that is designed to be connected to a security or life safety alarm or surveillance system component?

Average Active Mode Efficiency (%)

No-Load Mode Power Consumption (watts) (If Applicable)

Nameplate Output Power (watts)

Nameplate Output Voltage (volts)

Nameplate Output Current (amps)

Effective Wire Gauge (AWG) of the Recommended or Included Output Cord

Length (ft) of the Recommended or Included Output Cord

Pop-Up Headers:

Status

Manufacturer

Brand Name(s)

Basic Model Number

Individual Model Number

Action

Product Group Code

Sample Size

Certification Based on Waiver?

Date of Waiver, if Applicable

Cert. Based on Exception Relief?

Date of Relief, if Applicable

EPS Connected to Special Device?

Average Active Mode Efficiency

No-Load Power Consump., if appl.

Nameplate Output Power

Nameplate Output Voltage

Nameplate Output Current

Output Cord Wire Gauge

Output Cord Length

Pop-Up Contents:

The cells below show whether there are any issues with the data on that line. If the status is "ok," there are no issues. If the status is "Error," there are issues with the data. See columns to the right for an indication of the issues with the data.

Enter the Manufacturer name in the cells below.

Enter the Brand Name(s) in the cells below.

Enter the Basic Model Number in the cells below.

Enter the Individual Model Number covered by the Basic Model in the cells below.

Enter one of following in cells below: N new model D discontinued model C correction to previous CCMS submission E submit report on existing (carryover) model F failed Industry Certification Program .

Enter an integer between 1 and 25 in the cells below. See the Product Group Codes worksheet for details on product group codes.

Enter the sample size (number of units tested) in the cells below. This should be an integer greater than zero.

Answer whether the certification for the basic model was based on a waiver of DOE's test procedure requirements in the cells below. An affirmative answer can be either 'yes' or 'y' and a negative answer can be either 'no' or 'n'. .

If you enter 'yes' under "Is the certification for this basic model based on a waiver of DOE's test procedure requirements?", enter the date of the waiver in the cells below. The entry should be in the M/D/YYYY format. .

Answer whether the certification was based upon any exception relief from an applicable standard by DOE's Office of Hearing and Appeals in the cells below. An affirmative answer can be either 'yes' or 'y' and a negative answer can be either 'no' or 'n'.

If you enter 'yes' under "Is the certification based upon any exception relief from an applicable standard by DOE's Office of Hearing and Appeals?", enter the date of the exception relief in the cells below. The entry should be in the M/D/YYYY format.

Answer whether this is an AC-to-AC EPS designed to be connected to a security or life safety alarm or surveillance system component in the cells below. An affirmative answer can be either 'yes' or 'y' and a negative answer can be either 'no' or 'n'.

Enter the Average Active Mode Efficiency in percent in the cells below. This should be a percentage greater than zero and less than or equal to 100.

If the answer to the question in column R is 'no' or 'n' OR the Nameplate Output Power is <20 watts, enter the No-Load Mode Power Consumption in watts in the cells below. This should be a decimal number >0. Otherwise, leave the cell blank.

Enter the Nameplate Output Power in watts in the cells below. This should be a decimal number greater than zero. .

Enter the Nameplate Output Voltage in volts in the cells below. This should be a decimal number greater than zero. .

Enter the Nameplate Output Current in amps in the cells below. This should be a decimal number greater than zero.

Enter the effective wire gauge in AWG of the recommended or included output cord in the cells below.

Enter the length in feet of the recommended or included output cord in the cells below.

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Sheet 3: Product Group Code

The following is a description of each product group code:
Product Group Code	Product Group Code Description
1	Direct Operation, Single Voltage, AC-DC, nameplate output voltage >= 6 volts or nameplate output current < 550 milliamps, nameplate output power <= 1 watt
2	Direct Operation, Single Voltage, AC-DC, nameplate output voltage >= 6 volts or nameplate output current < 550 milliamps, 1 watt < nameplate output power <= 49 watts
3	Direct Operation, Single Voltage, AC-DC, nameplate output voltage >= 6 volts or nameplate output current < 550 milliamps, 49 watts < nameplate output power <= 250 watts
4	Direct Operation, Single Voltage, AC-DC, nameplate output voltage >= 6 volts or nameplate output current < 550 milliamps, nameplate output power > 250 watts
5	Direct Operation, Single Voltage, AC-DC, nameplate output voltage < 6 volts and nameplate output current >= 550 milliamps, nameplate output power <= 1 watt
6	Direct Operation, Single Voltage, AC-DC, nameplate output voltage < 6 volts and nameplate output current >= 550 milliamps, 1 watt < nameplate output power <= 49 watts
7	Direct Operation, Single Voltage, AC-DC, nameplate output voltage < 6 volts and nameplate output current >= 550 milliamps, 49 watts < nameplate output power <= 250 watts
8	Direct Operation, Single Voltage, AC-DC, nameplate output voltage < 6 volts and nameplate output current >= 550 milliamps, nameplate output power > 250 watts
9	Direct Operation, Single Voltage, AC-AC, nameplate output voltage >= 6 volts or nameplate output current < 550 milliamps, nameplate output power <= 1 watt
10	Direct Operation, Single Voltage, AC-AC, nameplate output voltage >= 6 volts or nameplate output current < 550 milliamps, 1 watt < nameplate output power <= 49 watts
11	Direct Operation, Single Voltage, AC-AC, nameplate output voltage >= 6 volts or nameplate output current < 550 milliamps, 49 watts < nameplate output power <= 250 watts
12	Direct Operation, Single Voltage, AC-AC, nameplate output voltage >= 6 volts or nameplate output current < 550 milliamps, nameplate output power > 250 watts
13	Direct Operation, Single Voltage, AC-AC, nameplate output voltage < 6 volts and nameplate output current >= 550 milliamps, nameplate output power <= 1 watt
14	Direct Operation, Single Voltage, AC-AC, nameplate output voltage < 6 volts and nameplate output current >= 550 milliamps, 1 watt < nameplate output power <= 49 watts
15	Direct Operation, Single Voltage, AC-AC, nameplate output voltage < 6 volts and nameplate output current >= 550 milliamps, 49 watts < nameplate output power <= 250 watts
16	Direct Operation, Single Voltage, AC-AC, nameplate output voltage < 6 volts and nameplate output current >= 550 milliamps, nameplate output power > 250 watts
17	Direct Operation, Multiple-Voltage, nameplate output power <= 1 watt
18	Direct Operation, Multiple-Voltage, 1 watt < nameplate output power <= 49 watts
19	Direct Operation, Multiple-Voltage, nameplate output power > 49 watts
20	Spare Part, Direct Operation, nameplate output power < 1 watt (subject to Level IV)
21	Spare Part, Direct Operation, 1 watt <= nameplate output power <= 51 watts (subject to Level IV)
22	Spare Part, Direct Operation, 51 watts < nameplate output power <= 250 watts (subject to Level IV)
23	Indirect Operation, nameplate output power < 1 watt (subject to Level IV)
24	Indirect Operation, 1 watt <= nameplate output power <= 51 watts (subject to Level IV)
25	Indirect Operation, 51 watts < nameplate output power <= 250 watts (subject to Level IV)