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**[ENERGY STAR]{.smallcaps} Product Information Form for Use by [ENERGY
STAR]{.smallcaps} Qualified Residential Ventilating Fan Partners
(Companies who have joined ENERGY STAR for Residential Ventilating Fans
by signing the Partnership Agreement)** *You may use this form to report
only those products that are sold under your company's brand name. If
your firm sells its models to another company that uses its own brand
name, that company must join the program and report its own products.
Information from this form will be added to the list of [ENERGY
STAR]{.smallcaps} qualified residential ventilating fan products.*

**Company Name:**

(As listed in Partnership Agreement)

#### Qualifying Product Information

  ------------- -------------- -------------- ------------- ------------ -------------
  **Brand**     **Model Name** **Model        **Number of   **Warranty   **Date
                               Number**       Speeds**^1^   (yrs)**      Product
                                                                         Available**

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

^1^ Applies only to bathroom and utility room fans, and in-line
ventilating fans, with more than one speed.

I.  **Product Performance: Range Hoods**

  -------------------------------- ------------ ---------- ------------ -------------- ------------
  **Configuration^2^**             **Airflow    **Motor    **Efficacy   **Sound level  **Airflow
                                   (cfm)^3^**   Wattage    (cfm/W)**    (sones)^5^**   Certified
                                                (W)^4^**                               Rating
                                                                                       (cfm)^6^**

  Horizontal                                                                           

  Vertical                                                                             

  Other:\_\_\_\_\_\_\_\_\_\_\_\_                                                       
  -------------------------------- ------------ ---------- ------------ -------------- ------------

^2^ Record product performance data for each configuration at which the
product was tested (i.e., vertical, horizontal, and/or other).

**Product Performance: Bathroom and Utility Room Fans, and In-line
Ventilating Fans**^7^

  -------------- ------------ ------------ ------------------- --------------
  **Airflow      **Motor      **Efficacy   **Sound level       **Airflow
  (cfm)^3^**     Wattage      (cfm/W)**    (sones)^5^**        Certified
                 (W)^4^**                                      Rating
                                                               (cfm)^6^**

                                                               

                                                               

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

^3^ Rounded down to the nearest whole Watt.

^4^ Report using three significant digits when wattage is greater than
10 watts, (e.g., 51.6 Watts, 516 Watts), or two significant digits when
wattage is less than 10 watts (e.g., 5.2 Watts).

^5^ Sound level measurements not required for single and multi-port
in-line fans.

^6^ If same as airflow cfm used to calculate efficiency, please report,
"same;" otherwise, report alternative certified rating.

^7^ If the product has more than one speed, record product performance
data for each speed, using one row per speed (sound level data is not
required for in-line ventilating fans).

**Note:** Ducted bathroom and utility room fans tested at 0.1 w.g.
static pressure. Single and multi-port in-line fans tested at 0.2 w.g.
static pressure. Non-ducted products tested at 0.3 w.g. static pressure.
Range Hoods tested at Working Speed as defined in "*HVI Supplement --
Range Hood Working Speed*."

**Ducted Bathroom and Utility Room Fans Only:**

Airflow at 0.25 w.g. static pressure: \_\_\_\_\_\_ cfm \_\_\_\_\_\_ % of
rated airflow at 0.1 w.g.

##### Testing

Testing must be performed by an independent 3^rd^ party laboratory. From
January 1, 2010, any laboratory testing fans under this specification
must also be accredited as per the ENERGY STAR Program Requirements for
Residential Ventilating Fans laboratory accreditation requirements.

Tested by: (Name of independent 3^rd^ party laboratory)

Date tested:

II. **Certification**

To participate in the ENERGY STAR program, each residential ventilating
fan model must be certified by the Home Ventilating Institute (HVI), Air
Movement and Control Association (AMCA), or another such organization as
approved by EPA. Certification includes both initial qualification
testing, as well as ongoing verification testing.

Is the product in the HVI directory (circle one)? Yes No

If so, under what name?

Is the product in the AMCA directory (circle one)? Yes No

If so, under what name?

Is the product in the directory of any additional certification
organization (circle one)? Yes No

If so, which organization, and under what name?

##### Lighting Requirements

**All light sources**: please complete the fields provided below (as
applicable).

**Fluorescent light sources**: Please complete fields and provide data
in Table 1 below.

**LED Light Engine light sources**: Please complete fields and provide
data in Table 2 below.

Date Tested:

Total Number of Lamps Used: \_\_\_\_\_\_

Maximum Total Listed Lamp Wattage: \_\_\_\_\_ watts

Maximum Total Night Light Wattage: \_\_\_\_\_\_ watts

+----------------------------------------------+-----------------------+
| **Table 1. Performance and Reporting         |                       |
| Requirements for Fluorescent Sources**       |                       |
+----------------------------------------------+-----------------------+
| Ballast type (check one)                     | -   Electronic        |
|                                              |                       |
|                                              | -   Magnetic          |
+----------------------------------------------+-----------------------+
| Ballast Manufacturer Name                    |                       |
+----------------------------------------------+-----------------------+
| Ballast Model Number                         |                       |
+----------------------------------------------+-----------------------+
| Lamp Manufacturer Name                       |                       |
+----------------------------------------------+-----------------------+
| Lamp Model Number                            |                       |
+----------------------------------------------+-----------------------+
| System Efficacy per Lamp Ballast Combination | Lumens                |
+----------------------------------------------+-----------------------+
|                                              | \_\_\_\_\_ Input      |
|                                              | Watts                 |
+----------------------------------------------+-----------------------+
|                                              | \_\_\_\_\_            |
|                                              | Lumens/Watt           |
+----------------------------------------------+-----------------------+
| Lamp Start Time                              | milliseconds          |
+----------------------------------------------+-----------------------+
| Lamp Life                                    | hours                 |
+----------------------------------------------+-----------------------+
| Color Rendering Index                        | CRI                   |
+----------------------------------------------+-----------------------+
| Correlated Color Temperature                 | Kelvin                |
+----------------------------------------------+-----------------------+
| Noise                                        | dBA                   |
+----------------------------------------------+-----------------------+
| Does lamp ship with the unit (circle one)?   | Yes No                |
+----------------------------------------------+-----------------------+

+----------------------------------+-----------------+-----------------+
| #### Table 2. Per                |                 |                 |
| formance and Reporting Requireme |                 |                 |
| nts for LED Light Engine Sources |                 |                 |
+----------------------------------+-----------------+-----------------+
| LED Light Engine Manufacturer    |                 | No              |
| Name                             |                 | documentation   |
|                                  |                 | required at     |
|                                  |                 | time of         |
|                                  |                 | submittal.      |
+----------------------------------+-----------------+-----------------+
| LED Light Engine Model Number    |                 |                 |
+----------------------------------+-----------------+-----------------+
| System Efficacy per Lamp Ballast | \_\_\_\_\_\_\_  | > A test report |
| Combination                      | Lumens          | > from a        |
|                                  |                 | > laboratory:   |
|                                  |                 |                 |
|                                  |                 | -   trained by  |
|                                  |                 |     a           |
|                                  |                 |                 |
|                                  |                 |  representative |
|                                  |                 |     of the      |
|                                  |                 |     Lighting    |
|                                  |                 |     Research    |
|                                  |                 |     Center      |
|                                  |                 |     (RPI) on    |
|                                  |                 |     behalf of   |
|                                  |                 |     the         |
|                                  |                 |     Alliance    |
|                                  |                 |     for         |
|                                  |                 |     Solid-State |
|                                  |                 |                 |
|                                  |                 |    Illumination |
|                                  |                 |     Systems and |
|                                  |                 |                 |
|                                  |                 |    Technologies |
|                                  |                 |     (ASSIST);   |
|                                  |                 |     or          |
|                                  |                 |                 |
|                                  |                 | -   qualified   |
|                                  |                 |     to          |
|                                  |                 |     participate |
|                                  |                 |     in the      |
|                                  |                 |     Department  |
|                                  |                 |     of Energy's |
|                                  |                 |     CALiPER     |
|                                  |                 |     program.    |
+----------------------------------+-----------------+-----------------+
|                                  | \_\_\_\_\_\_\_  |                 |
|                                  | Input Watts     |                 |
+----------------------------------+-----------------+-----------------+
|                                  | \_\_\_\_\_\_\_  |                 |
|                                  | Lumens/Watt     |                 |
+----------------------------------+-----------------+-----------------+
| Color Rendering Index            | \_\_\_\_\_\_\_  |                 |
|                                  | CRI             |                 |
+----------------------------------+-----------------+-----------------+
| Correlated Color Temperature     | \_\_\_\_\_\_\_  |                 |
|                                  | Kelvin          |                 |
+----------------------------------+-----------------+-----------------+
| Maximum Measured Driver/Driver   | \_\_\_\_\_\_\_  | Laboratory Test |
| Case Temperature (during *in     | degrees Celsius | Report.         |
| situ* operation)                 |                 |                 |
+----------------------------------+-----------------+-----------------+
| Lumen Maintenance                | \_\_\_\_\_\_\_  | -   Lumen       |
|                                  | hours to 70% of |     maintenance |
|                                  | initial lumens  |     and color   |
|                                  |                 |     stability   |
|                                  |                 |     data        |
|                                  |                 |     declared by |
|                                  |                 |     LED package |
|                                  |                 |                 |
|                                  |                 |   manufacturer, |
|                                  |                 |     in          |
|                                  |                 |     accordance  |
|                                  |                 |     with ASSIST |
|                                  |                 |     Sample Data |
|                                  |                 |     Sheet for   |
|                                  |                 |     High-Power  |
|                                  |                 |     LEDs (Issue |
|                                  |                 |     4); or      |
|                                  |                 |                 |
|                                  |                 | -   LED package |
|                                  |                 |     datasheets  |
|                                  |                 |     conforming  |
|                                  |                 |     to IESNA    |
|                                  |                 |     LM-80       |
|                                  |                 |     protocols,  |
|                                  |                 |     once the    |
|                                  |                 |     metric is   |
|                                  |                 |     available.  |
+----------------------------------+-----------------+-----------------+
| Color Stability                  | \_\_\_\_\_      |                 |
|                                  | meets           |                 |
|                                  | requirements    |                 |
+----------------------------------+-----------------+-----------------+
| 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.   |
+----------------------------------+-----------------+-----------------+
| Output Operating Frequency       | \_\_\_\_\_\_\_  |                 |
|                                  | Hz              |                 |
+----------------------------------+-----------------+-----------------+
| Noise                            | \_\_\_\_\_\_\_  | No              |
|                                  | dBA             | documentation   |
|                                  |                 | required at     |
|                                  |                 | time of         |
|                                  |                 | submittal.      |
+----------------------------------+-----------------+-----------------+
| Transient Protection             | \_\_\_\_\_      | Test report     |
|                                  | meets           | from a lab      |
|                                  | requirements    | 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.   |
+----------------------------------+-----------------+-----------------+
| Electromagnetic and Radio        | \_\_\_\_\_      | No              |
| Frequency Interference           | meets           | documentation   |
|                                  | requirements    | required at     |
|                                  |                 | time of         |
|                                  |                 | submittal.      |
+----------------------------------+-----------------+-----------------+
| Does lamp ship with the unit     | Yes No          |                 |
| (circle one)?                    |                 |                 |
+----------------------------------+-----------------+-----------------+

V.  **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 Ventilating Fans. These
requirements include:

+-----------------------------------+----------------------------------+
| -   On front of product           | -   In product literature        |
|     (required)                    |     (required)                   |
+-----------------------------------+----------------------------------+
| -   On product packaging          | -   On Internet site (required)  |
|     (recommended)                 |                                  |
+-----------------------------------+----------------------------------+

If answer to any of the above is no, explain why:

VI. **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         | -   Japan                         |
+-----------------------------------+-----------------------------------+
| -   Canada                        | -   Mexico                        |
+-----------------------------------+-----------------------------------+
| -   EU                            | -   Taiwan                        |
+-----------------------------------+-----------------------------------+

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