![](media/image1.png){width="0.8986111111111111in"
height="0.9111111111111111in"}

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**ENERGY STAR^[®]{.smallcaps}^ product information form for use by
ENERGY STAR qualified residential ceiling fan partners**

**(Companies who have joined ENERGY STAR for residential ceiling fans by
signing a** **Partnership Agreement)**

*You may use this form to report only those products that are sold under
the company's brand name. If* *your firm sells its models to another
company that uses its own brand name, that company must join ENERGY STAR
and report its own products. Information from this form will be added to
the list of ENERGY STAR qualified residential ceiling fan products.
Please copy this form and return one for each qualifying product model
to the address provided in Section IX of this form.*

**Company Name: Product Contact Information**

> **(As listed in Partnership Agreement) (verification of product
> information)**

Name:

Tel:

Fax:

Email:

I.  **Product Information --** List representative (tested) model first.
    Models that are identical to the representative model in every
    respect but finish may be listed in the table below.

+--------------+----------------+--------------+----------+-----------+
| **Brand      | **Model Name** | ### Mo       | ### Reta | ### Lamp  |
| Name**       |                | del Number\* | iler SKU |  Shipped  |
|              |                |              |  Number  | w/ Model? |
|              |                |              |          |           |
|              |                |              | ##       | (Light    |
|              |                |              | # (if av | Kits      |
|              |                |              | ailable) | only)     |
+--------------+----------------+--------------+----------+-----------+
| []{.mark}    | []{.mark}      |              | [        | Y OR N    |
|              |                |              | ]{.mark} |           |
+--------------+----------------+--------------+----------+-----------+
| []{.mark}    | []{.mark}      |              | [        | Y OR N    |
|              |                |              | ]{.mark} |           |
+--------------+----------------+--------------+----------+-----------+
| []{.mark}    | []{.mark}      |              | [        | Y OR N    |
|              |                |              | ]{.mark} |           |
+--------------+----------------+--------------+----------+-----------+
| []{.mark}    | []{.mark}      |              | [        | Y OR N    |
|              |                |              | ]{.mark} |           |
+--------------+----------------+--------------+----------+-----------+
| []{.mark}    | []{.mark}      |              | [        | Y OR N    |
|              |                |              | ]{.mark} |           |
+--------------+----------------+--------------+----------+-----------+
| []{.mark}    | []{.mark}      |              | [        | Y OR N    |
|              |                |              | ]{.mark} |           |
+--------------+----------------+--------------+----------+-----------+
| Fan Size     | Please Attach  |              |          |           |
| (in.):       | Fixture        |              |          |           |
|              | Description    |              |          |           |
|              | (Light         |              |          |           |
|              | Kit)[^1]       |              |          |           |
+--------------+----------------+--------------+----------+-----------+

**\*** Please include available finishes for the representative model;
use additional sheets, if necessary, and attach to this QPI form.

# Ceiling Fan Airflow Efficiency

  ------------------ -------------- ------------------ -------------------
  **Fan Speed**      **Airflow      **Fan Power        **Airflow
                     (CFM)**        Consumption        Efficiency
                                    (watts)**          (CFM/watt)**

                                                       

                                                       

                                                       
  ------------------ -------------- ------------------ -------------------

## Ceiling Fan Controls

Provide type and location of fan controls (wall-mounted switch, pull
chain, remote control):

+-----------------+----------------+----------------+----------------+
| **Type of Fan   | #### L         | #### Type      | #### Location  |
| Speed Control** | ocation of Fan | of Airflow Dir | of Airflow Dir |
|                 |  Speed Control | ection Control | ection Control |
+-----------------+----------------+----------------+----------------+
|                 |                |                |                |
+-----------------+----------------+----------------+----------------+
|                 |                |                |                |
+-----------------+----------------+----------------+----------------+
|                 |                |                |                |
+-----------------+----------------+----------------+----------------+

## Lighting Requirements (for all ceiling fan light kits: integral, attachable, or sold separately)

> **Pin-Based:** Light kit must be tested and qualify under Appendix A
> of the ENERGY STAR Version 2.1 Residential Ceiling Fan specification.
> Please provide test results in Section VIII of this form. [Testing
> documentation must be submitted with this form]{.underline}. **Note:
> If lamp/ballast combination has already been tested by OEM or other
> entity, you may submit an ENERGY STAR lamp/ballast qualification
> letter (provided by the OEM) in lieu of testing documentation, where
> applicable. Please note that some additional documentation may be
> required for qualification.**

Manufacturer Model/Product \#

CFL Wattage Number of CFLs Included in Packaging

## Warranty Requirements

**Note:** Ceiling fans and/or light kits must meet the following minimum
requirements:

> Motor: [\>]{.underline} 30 years
>
> Fan Components: [\>]{.underline} 1 year
>
> Light Kits: [\>]{.underline} 2 years

Motor Warranty: years

List Fan Components and their Warranties: [\_\_\_\_\_\_]{.underline}

Light Kit Warranty: years

# Labeling Requirements

By checking the boxes below, you are confirming that you have reviewed
and will meet the labeling requirements outlined in the ENERGY STAR
Program Requirements for Residential Ceiling Fans. These requirements
include:

 On product packaging/box  In product literature  On Internet site

Will the Performance and Efficiency Table be clearly displayed on the
outside of the product packaging (Ceiling Fans only)?  Yes  No

## Ceiling Fan Testing

All manufacturers are required to perform tests on residential ceiling
fan models by using the Solid State Test Method described in the Testing
Facility Guidance Manual: *Building a Test Facility and Performing the
Solid State Test Method for ENERGY STAR Qualified Ceiling Fans*. Fan
models identical in every respect but finish may be represented by a
single representative model for testing purposes. However, separate test
data is required for all models that differ in motor type or size,
housing size/shape/design, rotational speed, control type, or blade
weight, number, size, or pitch. **[Laboratory test results must be
attached to this form for a model to qualify as ENERGY
STAR.]{.underline}**

Tested By: Date Available (on market):

(Name of Qualified Testing Facility)

## Light Kit Test Results 

**Note:** Data and information needed to complete this section can be
provided by an accredited public or private laboratory, by the OEM, or
from an industry association, with the exception of the 2-year warranty
and Safety Documentation, which should be supplied by the ceiling fan
manufacturer. Values provided in the testing documentation must match
those values that are entered in the Test Results table, below.

Please check if applicable:

-   Submittal includes an ENERGY STAR lamp/ballast qualification letter
    for Version 4.0 of the Indoor Residential Lighting Fixture
    Specification.

+-------+----+----+---+---+---------------------+--------------------+
| *     |    |    |   |   |                     |                    |
| *LAMP |    |    |   |   |                     |                    |
| &     |    |    |   |   |                     |                    |
| BA    |    |    |   |   |                     |                    |
| LLAST |    |    |   |   |                     |                    |
| INFO  |    |    |   |   |                     |                    |
| RMATI |    |    |   |   |                     |                    |
| ON:** |    |    |   |   |                     |                    |
+-------+----+----+---+---+---------------------+--------------------+
| \*N   | Nu | \* | \ | L | Lamp (e.g., light   | Ballast            |
| umber | mb | In | * | a | bulb)               |                    |
| of    | er | di | L | m |                     | Manufacturer &     |
| L     | of | vi | a | p | Manufacturer &      | Model Number       |
| amps/ | B  | du | m |   | Model Number        |                    |
| Fi    | al | al | p | S |                     |                    |
| xture | la | Li |   | i |                     |                    |
|       | st | st | T | z |                     |                    |
|       | s/ | ed | y | e |                     |                    |
|       | F  | La | p | ^ |                     |                    |
|       | ix | mp | e | 2 |                     |                    |
|       | tu | W  | ^ | ^ |                     |                    |
|       | re | at | 1 |   |                     |                    |
|       |    | ta | ^ |   |                     |                    |
|       |    | ge |   |   |                     |                    |
+-------+----+----+---+---+---------------------+--------------------+
|       |    |    |   |   |                     |                    |
+-------+----+----+---+---+---------------------+--------------------+
| 1\.   |    |    |   |   |                     |                    |
| Lamp  |    |    |   |   |                     |                    |
| Type: |    |    |   |   |                     |                    |
| For   |    |    |   |   |                     |                    |
| exa   |    |    |   |   |                     |                    |
| mple, |    |    |   |   |                     |                    |
| CFL = |    |    |   |   |                     |                    |
| Co    |    |    |   |   |                     |                    |
| mpact |    |    |   |   |                     |                    |
| Fl    |    |    |   |   |                     |                    |
| uores |    |    |   |   |                     |                    |
| cent, |    |    |   |   |                     |                    |
| CR =  |    |    |   |   |                     |                    |
| Circ  |    |    |   |   |                     |                    |
| ular, |    |    |   |   |                     |                    |
| L =   |    |    |   |   |                     |                    |
| L     |    |    |   |   |                     |                    |
| inear |    |    |   |   |                     |                    |
|       |    |    |   |   |                     |                    |
| 2\.   |    |    |   |   |                     |                    |
| Lamp  |    |    |   |   |                     |                    |
| Size: |    |    |   |   |                     |                    |
| For   |    |    |   |   |                     |                    |
| exa   |    |    |   |   |                     |                    |
| mple, |    |    |   |   |                     |                    |
| T4,   |    |    |   |   |                     |                    |
| T5,   |    |    |   |   |                     |                    |
| or    |    |    |   |   |                     |                    |
| T8.   |    |    |   |   |                     |                    |
+-------+----+----+---+---+---------------------+--------------------+
| [(For |    |    |   |   |                     |                    |
| E     |    |    |   |   |                     |                    |
| NERGY |    |    |   |   |                     |                    |
| STAR  |    |    |   |   |                     |                    |
| use   |    |    |   |   |                     |                    |
| only) |    |    |   |   |                     |                    |
| Ge    |    |    |   |   |                     |                    |
| neric |    |    |   |   |                     |                    |
| Lamp  |    |    |   |   |                     |                    |
| Cod   |    |    |   |   |                     |                    |
| e:]{. |    |    |   |   |                     |                    |
| mark} |    |    |   |   |                     |                    |
+-------+----+----+---+---+---------------------+--------------------+

+---------------------+--------------+---+---+----+-----+----------------+
| **TEST RESULTS:**   |              |   |   |    |     |                |
| Enter results from  |              |   |   |    |     |                |
| test report         |              |   |   |    |     |                |
| (complete using     |              |   |   |    |     |                |
| average of three or |              |   |   |    |     |                |
| more samples) or    |              |   |   |    |     |                |
| manufacturer data   |              |   |   |    |     |                |
| as specified in the |              |   |   |    |     |                |
| ENERGY STAR Program |              |   |   |    |     |                |
| Requirements for    |              |   |   |    |     |                |
| Residential Light   |              |   |   |    |     |                |
| Fixtures Version    |              |   |   |    |     |                |
| 3.2 and attach      |              |   |   |    |     |                |
| required            |              |   |   |    |     |                |
| documentation to    |              |   |   |    |     |                |
| this form.          |              |   |   |    |     |                |
+---------------------+--------------+---+---+----+-----+----------------+
| **Performance       | ##### Te     |   |   |    |     | **Required     |
| Characteristic**    | st Result {# |   |   |    |     | D              |
|                     | test-result  |   |   |    |     | ocumentation** |
|                     | .unnumbered} |   |   |    |     |                |
|                     |              |   |   |    |     | (please attach |
|                     |              |   |   |    |     | to this form)  |
+---------------------+--------------+---+---+----+-----+----------------+
| Efficacy            | \_\_\_\_     | T |   |    |     | Test report    |
|                     | \_\_\_\_\_\_ | o |   |    |     | from a lab     |
|                     |              | t |   |    |     | accredited by  |
|                     |              | a |   |    |     | NVLAP or other |
|                     |              | l |   |    |     | EPA approved   |
|                     |              | L |   |    |     | documentation. |
|                     |              | u |   |    |     |                |
|                     |              | m |   |    |     |                |
|                     |              | e |   |    |     |                |
|                     |              | n |   |    |     |                |
|                     |              | O |   |    |     |                |
|                     |              | u |   |    |     |                |
|                     |              | t |   |    |     |                |
|                     |              | p |   |    |     |                |
|                     |              | u |   |    |     |                |
|                     |              | t |   |    |     |                |
|                     |              | \ |   |    |     |                |
|                     |              | [ |   |    |     |                |
|                     |              | [ |   |    |     |                |
|                     |              | ^ |   |    |     |                |
|                     |              | 2 |   |    |     |                |
|                     |              | ] |   |    |     |                |
|                     |              | \ |   |    |     |                |
|                     |              | ] |   |    |     |                |
+---------------------+--------------+---+---+----+-----+----------------+
|                     | \_\_\_\_     | \ |   |    |     |                |
|                     | \_\_\_\_\_\_ | * |   |    |     |                |
|                     |              | I |   |    |     |                |
|                     |              | n |   |    |     |                |
|                     |              | p |   |    |     |                |
|                     |              | u |   |    |     |                |
|                     |              | t |   |    |     |                |
|                     |              | P |   |    |     |                |
|                     |              | o |   |    |     |                |
|                     |              | w |   |    |     |                |
|                     |              | e |   |    |     |                |
|                     |              | r |   |    |     |                |
|                     |              | ( |   |    |     |                |
|                     |              | w |   |    |     |                |
|                     |              | a |   |    |     |                |
|                     |              | t |   |    |     |                |
|                     |              | t |   |    |     |                |
|                     |              | s |   |    |     |                |
|                     |              | ) |   |    |     |                |
|                     |              | \ |   |    |     |                |
|                     |              | [ |   |    |     |                |
|                     |              | [ |   |    |     |                |
|                     |              | ^ |   |    |     |                |
|                     |              | 3 |   |    |     |                |
|                     |              | ] |   |    |     |                |
|                     |              | \ |   |    |     |                |
|                     |              | ] |   |    |     |                |
+---------------------+--------------+---+---+----+-----+----------------+
|                     | \_\_\_\_     | L |   |    |     |                |
|                     | \_\_\_\_\_\_ | u |   |    |     |                |
|                     |              | m |   |    |     |                |
|                     |              | e |   |    |     |                |
|                     |              | n |   |    |     |                |
|                     |              | s |   |    |     |                |
|                     |              | P |   |    |     |                |
|                     |              | e |   |    |     |                |
|                     |              | r |   |    |     |                |
|                     |              | W |   |    |     |                |
|                     |              | a |   |    |     |                |
|                     |              | t |   |    |     |                |
|                     |              | t |   |    |     |                |
+---------------------+--------------+---+---+----+-----+----------------+
| Lamp Life           | \_\_\_\_     | A |   |    |     | Test report    |
|                     | \_\_\_\_\_\_ | v |   |    |     | from a lab     |
|                     |              | e |   |    |     | accredited by  |
|                     |              | r |   |    |     | NVLAP or one   |
|                     |              | a |   |    |     | of its MRA     |
|                     |              | g |   |    |     | signatories,   |
|                     |              | e |   |    |     | an EPA         |
|                     |              | R |   |    |     | approved       |
|                     |              | a |   |    |     | Platform       |
|                     |              | t |   |    |     | Letter of      |
|                     |              | e |   |    |     | Qualification, |
|                     |              | d |   |    |     | EPA-approved   |
|                     |              | H |   |    |     | documentation  |
|                     |              | o |   |    |     | from an        |
|                     |              | u |   |    |     | industry       |
|                     |              | r |   |    |     | association,   |
|                     |              | s |   |    |     | or a test      |
|                     |              |   |   |    |     | report from an |
|                     |              |   |   |    |     | ISO 9000       |
|                     |              |   |   |    |     | registered     |
|                     |              |   |   |    |     | facility.      |
+---------------------+--------------+---+---+----+-----+----------------+
| Lumen Maintenance   | \_\_\_\_     | \ |   |    |     |                |
|                     | \_\_\_\_\_\_ | % |   |    |     |                |
|                     |              | o |   |    |     |                |
|                     |              | f |   |    |     |                |
|                     |              | i |   |    |     |                |
|                     |              | n |   |    |     |                |
|                     |              | i |   |    |     |                |
|                     |              | t |   |    |     |                |
|                     |              | i |   |    |     |                |
|                     |              | a |   |    |     |                |
|                     |              | l |   |    |     |                |
|                     |              | l |   |    |     |                |
|                     |              | u |   |    |     |                |
|                     |              | m |   |    |     |                |
|                     |              | e |   |    |     |                |
|                     |              | n |   |    |     |                |
|                     |              | s |   |    |     |                |
|                     |              | a |   |    |     |                |
|                     |              | t |   |    |     |                |
|                     |              | 4 |   |    |     |                |
|                     |              | 0 |   |    |     |                |
|                     |              | % |   |    |     |                |
|                     |              | r |   |    |     |                |
|                     |              | a |   |    |     |                |
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|                     |              | d |   |    |     |                |
|                     |              | l |   |    |     |                |
|                     |              | a |   |    |     |                |
|                     |              | m |   |    |     |                |
|                     |              | p |   |    |     |                |
|                     |              | l |   |    |     |                |
|                     |              | i |   |    |     |                |
|                     |              | f |   |    |     |                |
|                     |              | e |   |    |     |                |
|                     |              | ( |   |    |     |                |
|                     |              | 4 |   |    |     |                |
|                     |              | , |   |    |     |                |
|                     |              | 0 |   |    |     |                |
|                     |              | 0 |   |    |     |                |
|                     |              | 0 |   |    |     |                |
|                     |              | h |   |    |     |                |
|                     |              | o |   |    |     |                |
|                     |              | u |   |    |     |                |
|                     |              | r |   |    |     |                |
|                     |              | m |   |    |     |                |
|                     |              | i |   |    |     |                |
|                     |              | n |   |    |     |                |
|                     |              | i |   |    |     |                |
|                     |              | m |   |    |     |                |
|                     |              | u |   |    |     |                |
|                     |              | m |   |    |     |                |
|                     |              | ) |   |    |     |                |
+---------------------+--------------+---+---+----+-----+----------------+
| \*Lamp Color        | \_\_\_\_     | C |   |    |     | Test report    |
| Rendering (CRI)     | \_\_\_\_\_\_ | R |   |    |     | from a lab     |
|                     |              | I |   |    |     | accredited by  |
|                     |              |   |   |    |     | NVLAP or other |
|                     |              |   |   |    |     | EPA approved   |
|                     |              |   |   |    |     | documentation. |
+---------------------+--------------+---+---+----+-----+----------------+
| \*Lamp Correlated   | Target CCT   | 2 |   | 3  | 35  | Test report    |
| Color Temperature   | (circle one) | 7 |   | 00 | 00K | from a lab     |
| (CCT)               |              | 0 |   | 0K |     | accredited by  |
|                     |              | 0 |   |    |     | NVLAP or other |
|                     |              | K |   |    |     | EPA approved   |
|                     |              |   |   |    |     | documentation. |
+---------------------+--------------+---+---+----+-----+----------------+
|                     |              | 4 |   | 5  | 65  |                |
|                     |              | 1 |   | 00 | 00K |                |
|                     |              | 0 |   | 0K |     |                |
|                     |              | 0 |   |    |     |                |
|                     |              | K |   |    |     |                |
+---------------------+--------------+---+---+----+-----+----------------+
|                     | Samples      | \ |   |    |     |                |
|                     | falling      | _ |   |    |     |                |
|                     | within       | \ |   |    |     |                |
|                     | 7-step Mac   | _ |   |    |     |                |
|                     | Adam ellipse | \ |   |    |     |                |
|                     |              | _ |   |    |     |                |
|                     |              | \ |   |    |     |                |
|                     |              | _ |   |    |     |                |
|                     |              | \ |   |    |     |                |
|                     |              | _ |   |    |     |                |
|                     |              | \ |   |    |     |                |
|                     |              | _ |   |    |     |                |
|                     |              | \ |   |    |     |                |
|                     |              | _ |   |    |     |                |
|                     |              | % |   |    |     |                |
+---------------------+--------------+---+---+----+-----+----------------+
| Lamp/Lampholder     | List         | \ |   |    |     | No             |
| Compatibility       | ANSI-IEC     | _ |   |    |     | documentation  |
|                     | Designated   | \ |   |    |     | required at    |
|                     |              | _ |   |    |     | time of        |
|                     | **Lamp Base  | \ |   |    |     | submittal.     |
|                     | Type**       | _ |   |    |     |                |
|                     |              | \ |   |    |     |                |
|                     |              | _ |   |    |     |                |
|                     |              | \ |   |    |     |                |
|                     |              | _ |   |    |     |                |
|                     |              | \ |   |    |     |                |
|                     |              | _ |   |    |     |                |
|                     |              | \ |   |    |     |                |
|                     |              | _ |   |    |     |                |
+---------------------+--------------+---+---+----+-----+----------------+
|                     | ANSI-IEC     | Y |   |    |     | For fixtures   |
|                     | Standardized | e |   |    |     | that do not    |
|                     | **Lamp**?    | s |   |    |     | use an         |
|                     |              | O |   |    |     | ANSI-IEC       |
|                     |              | R |   |    |     | standardized   |
|                     |              | N |   |    |     | lamp from ANSI |
|                     |              | o |   |    |     | C78.901 &      |
|                     |              |   |   |    |     | C78.81 or IEC  |
|                     |              |   |   |    |     | 60901 & 60081, |
|                     |              |   |   |    |     | supply a lamp  |
|                     |              |   |   |    |     | manufacturer   |
|                     |              |   |   |    |     | specification  |
|                     |              |   |   |    |     | sheet.         |
+---------------------+--------------+---+---+----+-----+----------------+
|                     | If "Yes",    | \ |   |    |     |                |
|                     | list         | _ |   |    |     |                |
|                     | ANSI-IEC     | \ |   |    |     |                |
|                     | **Lamp**     | _ |   |    |     |                |
|                     | Standard     | \ |   |    |     |                |
|                     | Data Sheet   | _ |   |    |     |                |
|                     | Number       | \ |   |    |     |                |
|                     |              | _ |   |    |     |                |
|                     |              | \ |   |    |     |                |
|                     |              | _ |   |    |     |                |
|                     |              | \ |   |    |     |                |
|                     |              | _ |   |    |     |                |
|                     |              | \ |   |    |     |                |
|                     |              | _ |   |    |     |                |
|                     |              | O |   |    |     |                |
|                     |              | R |   |    |     |                |
|                     |              | N |   |    |     |                |
|                     |              | / |   |    |     |                |
|                     |              | A |   |    |     |                |
+---------------------+--------------+---+---+----+-----+----------------+
| Lamp Labeling       | Check box if | - |   |    |     | A copy of the  |
| Requirement         | lamp         |   |   |    |     | actual         |
|                     | labeling     |   |   |    |     | language that  |
|                     | requirement  |   |   |    |     | will be        |
|                     | has been     |   |   |    |     | included on    |
|                     | met:         |   |   |    |     | the lamp base  |
|                     |              |   |   |    |     | or glass.      |
+---------------------+--------------+---+---+----+-----+----------------+
| **Ballast           |              |   |   |    |     |                |
| Requirements**      |              |   |   |    |     |                |
+---------------------+--------------+---+---+----+-----+----------------+
| Lamp Start Time     | \_\_\_\_     | M |   |    |     | Test report    |
|                     | \_\_\_\_\_\_ | i |   |    |     | from a lab     |
|                     |              | l |   |    |     | accredited by  |
|                     |              | l |   |    |     | NVLAP or one   |
|                     |              | i |   |    |     | of its MRA     |
|                     |              | s |   |    |     | signatories,   |
|                     |              | e |   |    |     | an EPA         |
|                     |              | c |   |    |     | approved       |
|                     |              | o |   |    |     | Platform       |
|                     |              | n |   |    |     | Letter of      |
|                     |              | d |   |    |     | Qualification, |
|                     |              | s |   |    |     | EPA-approved   |
|                     |              |   |   |    |     | documentation  |
|                     |              |   |   |    |     | from an        |
|                     |              |   |   |    |     | industry       |
|                     |              |   |   |    |     | association,   |
|                     |              |   |   |    |     | or a test      |
|                     |              |   |   |    |     | report from an |
|                     |              |   |   |    |     | OSHA NRTL      |
|                     |              |   |   |    |     | laboratory.    |
+---------------------+--------------+---+---+----+-----+----------------+
| Power Factor        | \_\_\_\_     |   |   |    |     | Test report    |
|                     | \_\_\_\_\_\_ |   |   |    |     | from a lab     |
|                     |              |   |   |    |     | accredited by  |
|                     |              |   |   |    |     | NVLAP or one   |
|                     |              |   |   |    |     | of its MRA     |
|                     |              |   |   |    |     | signatories,   |
|                     |              |   |   |    |     | an EPA         |
|                     |              |   |   |    |     | approved       |
|                     |              |   |   |    |     | Platform       |
|                     |              |   |   |    |     | Letter of      |
|                     |              |   |   |    |     | Qualification, |
|                     |              |   |   |    |     | EPA-approved   |
|                     |              |   |   |    |     | documentation  |
|                     |              |   |   |    |     | from an        |
|                     |              |   |   |    |     | industry       |
|                     |              |   |   |    |     | association,   |
|                     |              |   |   |    |     | or a test      |
|                     |              |   |   |    |     | report from    |
|                     |              |   |   |    |     | the ballast or |
|                     |              |   |   |    |     | fixture        |
|                     |              |   |   |    |     | manufacturer.  |
+---------------------+--------------+---+---+----+-----+----------------+
| Lamp Current Crest  | \_\_\_\_     |   |   |    |     | Test report    |
| Factor              | \_\_\_\_\_\_ |   |   |    |     | from a lab     |
|                     |              |   |   |    |     | accredited by  |
|                     |              |   |   |    |     | NVLAP, or one  |
|                     |              |   |   |    |     | of its MRA     |
|                     |              |   |   |    |     | Signatories,   |
|                     |              |   |   |    |     | or a lab       |
|                     |              |   |   |    |     | accredited by  |
|                     |              |   |   |    |     | an OSHA NRTL,  |
|                     |              |   |   |    |     | or other EPA   |
|                     |              |   |   |    |     | approved       |
|                     |              |   |   |    |     | documentation  |
+---------------------+--------------+---+---+----+-----+----------------+
| Maximum Recommended | \_\_\_\_\_   | d |   |    |     | Manufacturer   |
| Ballast Case        | \_\_\_\_\_\_ | e |   |    |     | or laboratory  |
| Temperature During  |              | g |   |    |     | data           |
| Normal Operation    |              | r |   |    |     |                |
| Inside Light Kit(s) |              | e |   |    |     |                |
|                     |              | e |   |    |     |                |
|                     |              | s |   |    |     |                |
|                     |              | C |   |    |     |                |
|                     |              | e |   |    |     |                |
|                     |              | l |   |    |     |                |
|                     |              | s |   |    |     |                |
|                     |              | i |   |    |     |                |
|                     |              | u |   |    |     |                |
|                     |              | s |   |    |     |                |
+---------------------+--------------+---+---+----+-----+----------------+
| Maximum Measured    | \_\_\_\_\_   | d |   |    |     | Test report    |
| Ballast Case        | \_\_\_\_\_\_ | e |   |    |     | from a lab     |
| Temperature During  |              | g |   |    |     | accredited by  |
| Normal Operation    |              | r |   |    |     | NVLAP or one   |
| Inside Light Kit(s) |              | e |   |    |     | of its MRA     |
|                     |              | e |   |    |     | signatories,   |
|                     |              | s |   |    |     | an OSHA NRTL   |
|                     |              | C |   |    |     | laboratory, or |
|                     |              | e |   |    |     | the fixture or |
|                     |              | l |   |    |     | ballast        |
|                     |              | s |   |    |     | manufacturer.  |
|                     |              | i |   |    |     |                |
|                     |              | u |   |    |     |                |
|                     |              | s |   |    |     |                |
+---------------------+--------------+---+---+----+-----+----------------+
| Electromagnetic and | Check box if | - |   |    |     | No             |
| Radio Frequency     | the ballast  |   |   |    |     | documentation  |
| Interference        | meets FCC    |   |   |    |     | required at    |
|                     | requirements |   |   |    |     | time of        |
|                     | for consumer |   |   |    |     | submittal.     |
|                     | use:         |   |   |    |     |                |
+---------------------+--------------+---+---+----+-----+----------------+
| Ballast Frequency   | \_\_\_\_     | k |   |    |     | Test report    |
|                     | \_\_\_\_\_\_ | H |   |    |     | from a lab     |
| (Required for all   |              | z |   |    |     | accredited by  |
| electronic          |              |   |   |    |     | NVLAP or one   |
| ballasts)           |              |   |   |    |     | of its MRA     |
|                     |              |   |   |    |     | signatories,   |
|                     |              |   |   |    |     | an EPA         |
|                     |              |   |   |    |     | approved       |
|                     |              |   |   |    |     | Platform       |
|                     |              |   |   |    |     | Letter of      |
|                     |              |   |   |    |     | Qualification, |
|                     |              |   |   |    |     | EPA-approved   |
|                     |              |   |   |    |     | documentation  |
|                     |              |   |   |    |     | from an        |
|                     |              |   |   |    |     | industry       |
|                     |              |   |   |    |     | association,   |
|                     |              |   |   |    |     | or a test      |
|                     |              |   |   |    |     | report from    |
|                     |              |   |   |    |     | the ballast or |
|                     |              |   |   |    |     | fixture        |
|                     |              |   |   |    |     | manufacturer.  |
+---------------------+--------------+---+---+----+-----+----------------+
| Transient           | Check box if | - |   |    |     |                |
| Protection          | ballast      |   |   |    |     |                |
|                     | meets        |   |   |    |     |                |
| (Required for all   | transient    |   |   |    |     |                |
| electronic          | protection   |   |   |    |     |                |
| ballasts)           | r            |   |   |    |     |                |
|                     | equirements: |   |   |    |     |                |
+---------------------+--------------+---+---+----+-----+----------------+
| End of Life         | Testing      |   | Y |    |     | Manufacturer   |
| Protection          | requirements |   | e |    |     | data or        |
| (Required for       | met?         |   | s |    |     | laboratory     |
| electronic ballasts |              |   | O |    |     | engineering    |
| with lamps sized T5 |              |   | R |    |     | description    |
| & smaller)          |              |   | N |    |     | outlining the  |
|                     |              |   | / |    |     | scheme that is |
|                     |              |   | A |    |     | used to        |
|                     |              |   |   |    |     | achieve end of |
|                     |              |   |   |    |     | life function  |
|                     |              |   |   |    |     | within the     |
|                     |              |   |   |    |     | ballast        |
+---------------------+--------------+---+---+----+-----+----------------+
|                     | Maximum      |   | \ |    |     |                |
|                     | number of    |   | _ |    |     |                |
|                     | lamps shut   |   | \ |    |     |                |
|                     | down when    |   | _ |    |     |                |
|                     | lamp end of  |   | \ |    |     |                |
|                     | life event   |   | _ |    |     |                |
|                     | occurs:      |   | \ |    |     |                |
|                     |              |   | _ |    |     |                |
|                     |              |   | \ |    |     |                |
|                     |              |   | _ |    |     |                |
|                     |              |   | \ |    |     |                |
|                     |              |   | _ |    |     |                |
|                     |              |   | \ |    |     |                |
|                     |              |   | _ |    |     |                |
|                     |              |   | O |    |     |                |
|                     |              |   | R |    |     |                |
|                     |              |   | N |    |     |                |
|                     |              |   | / |    |     |                |
|                     |              |   | A |    |     |                |
+---------------------+--------------+---+---+----+-----+----------------+
| Dimming             | Dim          | Y |   |    |     | No             |
|                     | ming-Capable | e |   |    |     | documentation  |
|                     | Ballast?     | s |   |    |     | required at    |
|                     |              | O |   |    |     | time of        |
|                     |              | R |   |    |     | submittal.     |
|                     |              | N |   |    |     |                |
|                     |              | o |   |    |     |                |
+---------------------+--------------+---+---+----+-----+----------------+
|                     | If "Yes",    | - |   |    |     |                |
|                     | Indicate     |   |   |    |     |                |
|                     | Dimming      |   |   |    |     |                |
|                     | Mechanism    |   |   |    |     |                |
|                     |              | 3 |   |    |     |                |
|                     |              | - |   |    |     |                |
|                     |              | W |   |    |     |                |
|                     |              | a |   |    |     |                |
|                     |              | y |   |    |     |                |
|                     |              |   |   |    |     |                |
|                     |              |   |   |    |     |                |
|                     |              |   |   |    |     |                |
|                     |              |   |   |    |     |                |
|                     |              | S |   |    |     |                |
|                     |              | w |   |    |     |                |
|                     |              | i |   |    |     |                |
|                     |              | t |   |    |     |                |
|                     |              | c |   |    |     |                |
|                     |              | h |   |    |     |                |
|                     |              | i |   |    |     |                |
|                     |              | n |   |    |     |                |
|                     |              | g |   |    |     |                |
|                     |              |   |   |    |     |                |
|                     |              | - |   |    |     |                |
|                     |              |   |   |    |     |                |
|                     |              |   |   |    |     |                |
|                     |              |   |   |    |     |                |
|                     |              | C |   |    |     |                |
|                     |              | o |   |    |     |                |
|                     |              | n |   |    |     |                |
|                     |              | t |   |    |     |                |
|                     |              | i |   |    |     |                |
|                     |              | n |   |    |     |                |
|                     |              | u |   |    |     |                |
|                     |              | o |   |    |     |                |
|                     |              | u |   |    |     |                |
|                     |              | s |   |    |     |                |
|                     |              |   |   |    |     |                |
|                     |              |   |   |    |     |                |
|                     |              |   |   |    |     |                |
|                     |              |   |   |    |     |                |
|                     |              | D |   |    |     |                |
|                     |              | i |   |    |     |                |
|                     |              | m |   |    |     |                |
|                     |              | m |   |    |     |                |
|                     |              | i |   |    |     |                |
|                     |              | n |   |    |     |                |
|                     |              | g |   |    |     |                |
+---------------------+--------------+---+---+----+-----+----------------+
| Safety -- Ballasts  | Listed for   | Y |   |    |     | Cover page of  |
| and "Non Edison     | Safety?      | e |   |    |     | a safety test  |
| base Fluorescent    |              | s |   |    |     | report or a    |
| Adapters"           |              | O |   |    |     | general        |
|                     |              | R |   |    |     | coverage       |
|                     |              | N |   |    |     | statement.     |
|                     |              | / |   |    |     |                |
|                     |              | A |   |    |     |                |
+---------------------+--------------+---+---+----+-----+----------------+
| **Light Kit         |              |   |   |    |     |                |
| Requirements**      |              |   |   |    |     |                |
+---------------------+--------------+---+---+----+-----+----------------+
| Light Kit Warranty  | Check box if | - |   |    |     | 2-Year Written |
|                     | fixture      |   |   |    |     | Fixture        |
|                     | warranty is  |   |   |    |     | Warranty       |
|                     | included     |   |   |    |     |                |
|                     | with light   |   |   |    |     |                |
|                     | kit          |   |   |    |     |                |
|                     | packaging:   |   |   |    |     |                |
+---------------------+--------------+---+---+----+-----+----------------+
| Noise               | \_\_\_\_     | d |   |    |     | Manufacturer   |
|                     | \_\_\_\_\_\_ | B |   |    |     | or laboratory  |
|                     |              | A |   |    |     | data           |
+---------------------+--------------+---+---+----+-----+----------------+
| Lamp Shipment       | Lamp(s)      | - |   |    |     | No             |
| Requirement         | intended for |   |   |    |     | documentation  |
|                     | use with     |   |   |    |     | required at    |
|                     | light kit(s) |   |   |    |     | time of        |
|                     | included?    |   |   |    |     | submittal.     |
+---------------------+--------------+---+---+----+-----+----------------+
| Replaceable Ballast | Check box if | - |   |    |     | A copy of the  |
|                     | the          |   |   |    |     | language that  |
|                     | submitted    |   |   |    |     | includes       |
|                     | light kit(s) |   |   |    |     | guidance on    |
|                     | meet(s) the  |   |   |    |     | ballast        |
|                     | replaceable  |   |   |    |     | replacement    |
|                     | ballast      |   |   |    |     | and states     |
|                     | requirement: |   |   |    |     | that the       |
|                     |              |   |   |    |     | ballast is     |
|                     |              |   |   |    |     | replaceable    |
|                     |              |   |   |    |     | with the use   |
|                     |              |   |   |    |     | of a           |
|                     |              |   |   |    |     | "qualified     |
|                     |              |   |   |    |     | electrician"   |
|                     |              |   |   |    |     | without the    |
|                     |              |   |   |    |     | cutting of     |
|                     |              |   |   |    |     | wires.         |
+---------------------+--------------+---+---+----+-----+----------------+
| Safety -- Hardwired | Listed for   | Y |   |    |     | Cover page of  |
| Fixtures            | Safety?      | e |   |    |     | a safety test  |
|                     |              | s |   |    |     | report or a    |
|                     |              | O |   |    |     | general        |
|                     |              | R |   |    |     | coverage       |
|                     |              | N |   |    |     | statement      |
|                     |              | / |   |    |     | included       |
|                     |              | A |   |    |     |                |
+---------------------+--------------+---+---+----+-----+----------------+
| Product Packaging   | Does the     | Y |   |    |     | Written copy   |
| for Consumer        | packaging    | e |   |    |     | or PDF graphic |
| Awareness           | clearly      | s |   |    |     | of the         |
| Requirements        | describe the | O |   |    |     | language that  |
|                     | target CCT   | R |   |    |     | will be        |
|                     | designation  | N |   |    |     | displayed on   |
|                     | in Kelvin?   | / |   |    |     | product        |
|                     |              | A |   |    |     | packaging and  |
|                     |              |   |   |    |     | within the     |
|                     |              |   |   |    |     | packaging, as  |
|                     |              |   |   |    |     | required.      |
+---------------------+--------------+---+---+----+-----+----------------+

\* Items with an asterisk will appear on the ENERGY STAR Web site.

##### Additional Information

Please list all major retailers that carry the product (attach a list if
necessary):

Please check one or more of the following international markets where
these products are sold (if applicable)?

 Australia/New Zealand  Canada  EU  Japan  Mexico  Taiwan

This Qualified Product Information Form and the Program Requirements for
Residential Ceiling Fans can be found in the Partner Resources section
of the ENERGY STAR Web site at
[www.energystar.gov](http://www.energystar.gov/).

Please submit your completed Qualified Product Information Form and
testing documentation one of the following ways:

**E-mail** testing results/QPI forms to <ceilingfans@icfi.com>

**Fax** results/QPI forms to Elliott Rector at (202) 862-1144

**US Mail/Overnight/Express** results/QPI forms to: Elliott Rector, ICF
International, 1725 Eye Street NW, Suite 1000, Washington, DC 20006

The public reporting and recordkeeping burden for this collection of
information is estimated to average 4.85 hours or minutes 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 Ave.,
NW, Washington, D.C. 20460. Include the OMB control number in any
correspondence. Do not send the completed form to this address.

[^1]: The fixture description should include brief information about
    finish, glass types, and any other aesthetics for consumer benefit.
    Descriptions may be submitted either electronically or as an
    attachment to this form.

[^2]: Total Lumen Output = (Lumens) x (# Lamps per Fixture) x (#
    Ballasts per fixture) x (Ballast Factor)

[^3]: From ballast specification