Survey Form and Submission/Filling Instructions on Chemical Substances in Supply Items
1.

Survey items(1) Confirmation of EU RoHS Directive compliance regarding environment-related substances.
(2) Confirmation of ”Section 5.1(4) Environment-related Substances [Rank A - Prohibited substances][Rank
B - Controlled substances]” in the Guidelines regarding environment-related substances.
(3) Confirmation of use/non-use of Substances of Very High Concern (SVHC,*1) under the REACH
Regulations as listed in ”Section 5.1(4) ”Environment-related Substances [Rank B – Controlled
substances]” in the Guideline.
(4) Survey on the content of chemical substances under EU REACH Regulations (chemSHERPA® form(*2)
and others)(5) Survey on the analysis and evaluation result.
Form and Scope of Survey
No.

Form

Name
Scope of Survey
Use/Non-use
Declaration ofForm 5-1 Environment-related
RoHS Directive restricted substances
Substances1… 10 items (Note1)(substance addition version)
Save as above
Form 5-2
Additional Item List
Survey on
Environment-related
Substances (restricted
RoHS Directive restricted substances andForm 3-1
substances other than
SVHC under REACH Regulations — Prohibited
2
RoHS Directive/
substances/controlled substances excluding (*3)
controlled substances)in the separate list
Save as above
Form 3-2
Additional Item List
Report on theForm 4-1 Presence of
REACH SVHCSVHC under REACH Regulations — (*3)
3
in the separate list
List of Products
Form 4-2 Containing REACH
SVHC
Note 1: Form 5 for substance addition version (A52 to A55 in Table2, phthalate ester (DEHP, BBP, DBP,
DIBP)) was added by this revision. It uses together with Form 2.
Excel files for the above Declaration/Survey/Report will be posted at our website.
File sheet description
No.1 includes “[Attached List -1] Exemption (Attachment III)”, “[Attached List -2] Exemption (AttachmentIV)” and Revision History in addition to the above “[Form 5-1] Declaration” and “[Form 5-2] Additional
Item List”.
No.2 includes “[Attached List -1] Prohibited Substances”, “[Attached List - 2] Controlled Substances”
and Revision History in addition to the above “[From 3-1] Survey” and “[Form 3-2] Additional Item List”.
No. 3 includes “List of Products Containing SVHC (Entry Example)” in addition to the above “[From 4-1]
Report on the Presence of SVHC” and “[Form 4-2] List of Products Containing SVHC.”(*1) Substances of Very High Concern (SVHC) are those which fall under Article 57 of the EU REACH
Regulations, and have been selected as substances subject to authorization in accordance with theprocedures of Article 59.
(*2) chemSHERPA® form is a common scheme provided by JAMP for transfer information about chemical
substances in products.
(*3) Since items of SVHC under EU Regulations may be added as necessary, the SVHC list is provided as aseparate list. Please refer to the SVHC list posted at our website:2. Submission instructions for Declaration/Survey(1) Sending of Declaration
Our research department will send you a Use/Non-use Declaration by e-mail for every model of parts and otheritems.
(2) Survey on restricted chemical substances
Survey on restricted chemical substances for target items(3) Submission of response documents
Please give us a reply according to the method requested by our research department.

Notes:
1. Please respond by the specified deadline to enable us to examine parts replacement or adaption of
new parts.
2. In cases where no response is received by the specified deadline, continued use or new use may not
be possible. When there is any special reason for a delay in responding, please contact us.
3. Response documents should be basically submitted per our purchasing unit (that is, every partscode). However, for finished products, units, etc., we may request a response per component part.
4. When impropriety is found in the survey results and we incur any damage due to the impropriety, we
may claim compensation for the damage.
5. If a survey request is issued to a discontinued item or an item to be discontinued (an item for which
discontinuation has been decided), please fill in the Discontinued column along with the response
details.
3.

Filling instructions for Declaration/Survey
Please fill in "Use/No-use Declaration of Environment-related Substances (substance addition version)[Form 5-1]” and "Survey on Environment-related Substances (restricted substances other than RoHS
Directive/controlled substances) [Form 3-1]” with the following instructions.

(1) Common instructions for [Form 5-1] and [Form 3-1]
1. When filling out the form
・Please complete the survey form by your company or by manufacturers of parts, units or materials as
far as possible.
・When there are more than one manufacturing base or supply route for the survey items, please reply
so that they are all covered . If the response information differs according to the manufacturing base or
supply route, please give us a reply for the worst case.

2. Company name and Respondent column
・Please enter official company name, not an abbreviation.
・Please enter department, title, name, telephone number, E-mail address of the person who fills in thedata [This will be used as contact information if we have any questions about the reply details].
3. Response date and Responsible person column
・For Response date, please use the Western calendar.
・Please enter company name, department name, title, name and E-mail address of the person who is
responsible for the response.
・Please enter company name, department name and title in the Responsible person column even if the
respondent and the responsible person are the same.
・Please append a company seal, or a department seal of the responsible person.
4. Remarks column
・Please specify if you have any substitute which does not contain chemical substances, and also fill in
the release time, etc. of such substitute. If you cannot fit all the information in the column, pleaseattach an additional sheet (the substitute information will be used for examining use after confirming
the procurement track records).
・You can enter supplementary information in the Comments column for each chemical substance or
explanation of the following 5.
5. Discontinued column/Discontinued Date (Plan) column
・If the target item has been discontinued or the discontinuation date has been already fixed, please
enter an “O” mark in the Discontinued column, and specify the year, month and date of the
discontinuation (please fill in the Presence of substance column even if the item is discontinued).

(2) [Form5-1]
1. “1. Target Item” column
・Please use separate Declaration forms when the content of “2. Response column” differs even if they
are in the same series.
・Parts code/Supplier parts code column is filled in at our company, if any, but the entry may berequested for the attached list, etc. In addition, there is a case where the Parts code is not yet
determined for the parts before use.
・In the case of parts and units, please enter product name, manufacturer name, manufacturer model
number and series name in each column.
In the case of materials such as resin, paint and ink, please enter information that can identify thetarget item in the manufacturer model number and series name fields.
・When you cannot fit all the target items in the designated column, please fill in the separate sheet“[Form 5-2] Additional Item List” and attach it. In this case, please enter the total number of pages inthe "Additional item list attached” column of “[Form 5-1].”
2. “2. Response column”
・For Presence of substance, please select “Yes” when an item includes a part that exceeds thethreshold limit value, regardless of whether it is added intentionally or otherwise (the threshold limit
values are shown in Appendix 1 below).
・Please select either “Yes” or “No” in each Presence of substance column, and select “Conformity” or“Non-conformity” in the RoHS Directive conformity determination column.
[“Yes” and “Non-conformity” are initially set].
・Please fill in Concentration*1 (ppm), Comments, and Remarks as far as possible, although they are
not mandatory when any substance exists.
・In the case of RoHS Directive exemption, please select "Exemption number or impurities" in theComment column, and enter details such as parts containing substances and usage. Please refer to“[Attached List -1] Exemption (Attachment III)” and “[Attached List -2] Exemption (Attachment IV)”.
・Please refer to Supplement 2 below for examples of entry about parts containing substances andpurpose of use in the Comments column.
・For discontinued or soon-to-be discontinued (already decided to be discontinued) items, please enteran “O” mark in the Discontinued column, and enter the discontinuation date (or planned discontinueddate) in the Discontinued date (plan) column.
(Even in the case of discontinued items, please reply about their substance inclusion as far as
possible. Please enter “Non-conformity” in the RoHS Directive conformity determination column
when unclear).
・ If you cannot give us a reply, please contact the person requesting the survey separately.

Appendix 1: Threshold Limits
The threshold limits of specified hazardous substance concentration are listed in Table 6.
Please determine whether substances are subject to the RoHS Directive by using the thresholdvalues below, regardless of whether or not the contained substances have been intentionallyadded.
The concentration of specified hazardous substances means the content rate of specified
hazardous substances in homogeneous materials such as products or parts (the “homogeneousmaterials” refer to materials that are uniform in composition and mechanically inseparable. Please
note that separate judgments are necessary for an electronic part, and solder or steel and paint,
because solder or paint can be separated from an electronic part or steel).
Specified Hazardous Substances Subject to RoHS Directive and Threshold Limits
Threshold limit
Specified Hazardous SubstancesNo.
(Percentage
by(* Includes metal compounds)
weight *1)
1
Cadmium/cadmium compounds*
0.01
2
Hexavalent chromium compounds*
0.1
3
Mercury/mercury compounds*
0.1
4
Lead/lead compounds*
0.1
5
Polybrominated biphenyls (PBBs)
0.1
6
Polybrominated diphenylethers (PBDEs)
0.1
7
Bis (2-ethylhexyl) phthalate (DEHP)
0.1
8
Dibutyl phthalate (DBP)
0.1
9Butyl benzyl phthalate (BBP)
0.1
10
Diisobutyl phthalate (DIBP)
0.1

(ppm)
100
1000
1000
1000
1000
1000
1000
1000
1000
1000

Note 1: By this revision, it added for RoHS Directive addition substance. (A52 to A55 in Table2,
phthalate ester (DEHP, BBP, DBP, DIBP))*1 Percentage by weight = Weight of contained substance / Weight of raw material
Example: Lead concentration (percentage by weight) = Weight of lead contained in solder / Weight ofsolderAppendix 2: Examples of entry of parts containing substances and purpose of use[Contained part]
The term “parts containing substances” refers to a component area of parts that contains specified
hazardous substances.
Please reply by using general names such as the names indicated on specifications and drawings,
or the internal names at the supplier. In addition, when the same substance is contained in two or
more parts, please enter the information respectively in multiple lines provided for each substance.
Please enter information for the main parts if you cannot fit them all in. In this case, please indicate
in the Comment or Remarks column that there are some other parts that have not been listed on
the form. The following are examples of a part.
< Examples of a part>・When a survey item is a single electronic part, an article that is listed on the block diagram,component materials list and other items is assumed to be a part.
Example 1: Ceramic material, internal electrode material, and external electrode material in a
multi-layer ceramic capacitor
Example 2: Lead wires, electrolysis solution, sealing material, and electrode foil in an electrolytic
capacitor
Example 3: Rubber contacts and springs in a switch and the plastic cover・When a survey item is a system component or unit (such as a device or assembled electronicpart), a part refers to an individual part recorded on the part’s (device’s) block diagram or parts list.
Examples: printed board, solder for use in assembly[Purpose of Use]
Please briefly fill in the purpose of contained chemical substances and the intention for using
them.
Example 1: Stabilizer, elasticizer, adhesive, fire retardant, anticorrosive, solder component
Example 2: Key ingredient, heat stability improvement, electrical property improvement,
mechanical property improvement
Example 3: Impurity (when it is clear that the substance is not contained intentionally)(3) [Form 3-1]
1. “1. Target Item” column
・Please use separate Survey forms when the content of “2. Response column” differs even if they arein the same series.
・Parts code/Supplier parts code column is filled in at our company, if any, but the entry may berequested for the attached list, etc. In addition, there is a case where the Parts code has not yet
been determined for the parts before use.
・In the case of parts and units, please enter product name, manufacturer name, manufacturer model
number and series name in each column.
In the case of materials such as resin, paint and ink, please enter information that can identify thetarget items in the manufacturer model number and series name fields.
・Please choose the unit of a product from “piece/g/kg/mm/m/cm2/ m2/ cc/l (liter) or m3” in the survey.
・For product weight, please enter weight per the above unit.
・When you cannot fit all the target items in the designated column, please fill in the separate sheet“[Form 3-2] Additional Item List” and attach it. In this case, please enter the total number of pages inthe "Additional item list attached” column of “[Form 3-1].”
2. “2. Response” column
・For prohibited substances A01, A02, A07, A09 to A15, A56, please select either “Yes” or “No” in the
Presence of substance column.
For other prohibited substances (other than RoHS restricted substances), please fill in thecorresponding number and substance name from “[Attached List -1] Prohibited Substances”, andselect “Yes” in the Presence of substance column.
When no substance is contained, please delete “Yes”. When any substance is contained, please fillin concentration, parts containing substances and purpose of use.
・For the controlled substances B04, B14, please select either “Yes” or “No” in the Presence of
substance column.
・For discontinued or soon-to-be discontinued (already determined to be discontinued) parts,
please enter an “O” mark in the Discontinued column, and enter the discontinuation date (orplanned discontinuation date) in the Discontinuation date (plan) column.
(Even in the case of a discontinued item, please reply about substance inclusion, etc., as far as
possible. When unknown, please leave the initial setting “Yes” in the Presence of substancecolumn, and write down a reason in the Remarks column”).
・If you cannot give us a reply, please contact the person requesting the survey separately.

4. Submission/filling instructions for SVHC Report
Please submit "Report on the Presence of REACH SVHC [Form 4-1]” and"List of Products Containing REACH SVHC [Form 4-1]” with the following instructions.

(1) Request for submission of the report
Our research department will send you a request for a report by e-mail, etc. periodically (at least
once per year). We may sometimes ask you for an additional report by specifying particular parts dueto (a response to additional SVHC) or an occasional request from customers.
(2) Survey on the presence of SVHC
We ask you to do a survey on the presence of newly added SVHC to control the chemical
substances contained in your products.
(3) Submission of the report
Please give us the following information after the survey.
1. There is no intentional inclusion or known inclusion in all your products.
Fill in the (1) Supplier Information column, and select No. 1 for the (2) Presence of ProductsContaining SVHC column in “[Form 4-1] Report on the Presence of REACH SVHC.”(Note) Since No. 2 (i.e., the inclusion is present) is initially set, be sure to change the selection.
2. There is intentional inclusion or known inclusion in your products.
Fill in the (1) Customer Information column, and confirm that No. 2 is selected for the (2)Presence of Products Containing SVHC column in “[Form 4-1] Report on the Presence of REACH
SVHC.”
Please provide us the information specified in the (3) SVHC Information column by one of thefollowing methods:
・Reply with the form provided by JAMP(chemSHERPA® form).
・Reply by using “[Form 4-2] List of Products Containing REACH SVHC.” In this case, please use
the entry example as a guide for entry.