OMB Control Number 2040-0272 Approval Expires 01/31/2010


# Promotional Partner Annual Reporting

EPA WaterSense ® Program Partners: Please complete and submit to WaterSense by March 1, 2010.

Section I: General Information

Organization Name: _____________________________________________________________________________

Contact Name: ____________________________ Email: ____________________________________________

Telephone: _______________________________ If water provider, population served:

______________________

Section II: Promotional Activities

1. Please indicate what types of WaterSense promotional acti vities you conducted last year and what you plan to implement in 2010.

Activities 2009 2010

Web site promotion with link to WaterSense  

Print advertising  

Television/radio advertising  

Newsletter or trade journal article (Journal: date: )  

Consumer handouts  

Public signage (Type: e.g., billboards, bus stops)  

Exhibit(s) at public fair, conferences, events  

Bill insert  

Workshops for consumers  

Workshops/training for contractors  

Presentation(s) to schools, community groups, etc.  

Promotion of WaterSense irrigation partners  

Recruitment of new WaterSense partners  

Incentive programs (e.g., tax-free holidays, rebates):  

Other (Please describe: )  

2. If you participated in the 2009 Fix a Leak Week (Mar. 16-20), please describe your activities:

3. To help WaterSense plan for the future, please describe your efforts in other water conservation areas such as

commercial programs and plumber outreach:Section III: Incentive Programs

Please provide the following information for each inc entive amount and quantity issued between January 1, 2009, and December 31, 2009. If you have a tracking sheet, feel free to attach it to this form.

Type of Product Type of Incentive

(e.g., rebate, giveaway, tax-free holiday) Number of Incentives Issued

WaterSense Non-WaterSense Combination

Toilets*

Bathroom Sink Faucets

Bathroom Sink Aerators or other faucet
accessories
Other

* Only toilets that are ≤ 1.28 gpf can earn the WaterSense label, though not all ≤ 1.28 gpf (high-efficiency) toilets are
WaterSense labeled. Please refer to the WaterSense labeled product list at www.epa.gov/watersense.

Section IV: WaterSense Prog ram Feedback (Optional)

In the interest of serving you better, EPA would like to learn more about your opinions regarding the WaterSense program and information needs. Please complete the following section to provide feedback to EPA.

1. On a scale of 1 to 5 (5 = most valuable), how valuable do you find the WaterSense program? Value: ____________

How has WaterSense added value? _______________________________________________________________

2. On a scale of 1 to 5 (5 = most valuable), how valuable did you find the materials from the promotional tool kit? Value: ______

3. Please provide suggestions for improving the WaterSense program (e.g., tools/materials, communications, Helpline, Web site, etc):

Please submit to the WaterSense Helpline by March 1, 2010.
Fax: ( 703) 841-1440
Mail: 2300 Wilson Blvd., Ste. 350, Arlington, VA 22201 Electronically: If you have Adobe Acrobat Standard or Professional, you can complete the form electronically and
e-mail it to watersense@epa.gov . Acrobat Reader users must print forms after completing and fax or mail them. Contact the WaterSense Helpline at (866) 987-7367 if you have any questions about how to complete this form or
submission instructions.

EPA Form Number 6100-09

The public reporting and record keeping burden for this collection of information is estimated to average 18 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 Stra tegies Division, U.S. Environm ental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any co rrespondence. Do not send the completed annual data form to t his address.