F349(GC)env03
ECOCERT Greenlife
10/03/2010
Questionnaire for non organic raw material checking according
to Ecocert standard new version
This questionnaire must be completed by the manufacturer of the raw material; Information given
is under his own responsibility.
COMMERCIAL NAME:
I General information about your company and your product:
1. Raw Material manufacturer (address, telephone, fax) :
2. Supplier/Distributor, if different (address, telephone, fax) :
3. Category/Function :
4. Chemical formula :
5. CAS number:
6. INCI name:
II –Reagents origin and manufacturing processes:
1. Chemically processed ingredients:
For each chemically processed agro-ingredient, please answer the following questions: (Example:
Glyceryl Stearate)
A Reagents
List of reagents of plant origin, manufacturing process and content:
- Glycerol, saponification of a vegetable oil, X%
- Stearic acid, saponification, neutralization and distillation without solvent of a vegetable oil, X%
List of reagents of mineral origin, manufacturing process and content:
List of reagents of marine origin, manufacturing process and content:
List of reagents of synthetic origin, manufacturing process and content:
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F349(GC)env03
ECOCERT Greenlife
10/03/2010
Indicate for each of the following processes whether it enters in the manufacturing of used
reagents:
 Ethoxylation :
 Irradiation :
 Sulfonation :
 Techniques using genetic manipulations :
 Ethylene oxide treatment :
 Treatment using mercury :
 Extraction :
(Specify the solvents used for extraction)
YES
YES
YES
YES
YES
YES
YES
Do you use the following products among your reagents: MEA, DEA, TEA ?
Are all raw materials in bio technologic processes GMO free?
Are the plants where reagents come from guaranteed GMO free ?
YES
YES
NO
NO
NO
NO
NO
NO
NO
YES
NO
NO
NO
(Join a non-GMO attestation or a negative PCR analysis)
B Origin of manufacturing auxiliaries :
Indicate for each of the following processes whether it enters in the manufacturing auxiliaries (pH
adjuster, catalyst …):
 Ethoxylation :
 Irradiation :
 Sulfonation :
 Techniques using genetic manipulations :
 Ethylene oxide treatment :
 Treatment using mercury :
 Extraction :
(Specify the solvents used for extraction) :
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
Do you use the following products among your manufacturing auxiliaries : MEA, DEA, TEA ?
YES
NO
C Manufacturing process of the product to be validated:
Manufacturing process description :
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F349(GC)env03
ECOCERT Greenlife
10/03/2010
Indicate for each of the following processes whether it enters in the product manufacturing:
 Ethoxylation :
YES
NO
 Irradiation :
YES
NO
 Sulfonation :
YES
NO
 Techniques using genetic manipulations :
YES
NO
 Quaternization of
YES
NO
 Ethylene oxide treatment :
YES
NO
 Treatment using mercury :
YES
NO
 Use of solvents for the manufacturing and the purification of your chemically
transformed ingredient :
YES
NO
 In that case, do you use aromatic, halogenated, sulfured, or nitrogened solvents ?
YES
NO
(Specify the solvents used for extraction) :






Hydrogenation :
Hydrolysis :
Esterification :
Etherification :
Sulphatation :
Fermentation :
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
Indicate the percentage of Active Matter of your chemically transformed ingredient:
D General questions regarding to the principles of green chemistry:
 Atoms economy principle: last reaction’s output
R= (mass of the wanted product/mass of all products)*100
What is the result? (must be specified for all chemically processed agroingredients) R =
 During the manufacturing of your chemically transformed ingredient, are there
intermediary reactions?
YES
NO
Have you set up a procedure to reduce the number of these reactions?
YES
NO
E Other questions:
If your ingredient contains a synthetic moiety, as authorized in the Standard, appendix VI,
Specify hereby the presence percentage of this moiety (on the active matter), as well as the
ingredient involved:
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F349(GC)env03
ECOCERT Greenlife
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2. Physically processed ingredients :
A Plant ingredients:
List here all the plant ingredients present in your raw material and their percentage as well
as the manufacturing processes that were needed for their preparation:
- Example: Sunflower oil, 5%, obtained by cold pressing
 Have a solvent of petrochemical origin been used for obtaining these ingredients:
YES
NO
 If yes, which one? :
 Are the plants initially used guaranteed GMO free?
YES
NO
B Animal origin ingredients:
List here all ingredients from animal origin present in your raw material and their
percentage:
- Example: Bees Wax, 5%.
 Are the ingredients listed above entailing the death of the animal?:
YES
NO
 Have a solvent of petrochemical origin been used for obtaining these ingredients:
YES
NO
If yes, which one? :
C Mineral origin ingredients:
List here all ingredients from mineral origin of your raw material and their percentage, as
well as the physical processes that were needed for their preparation:
- Example: Calcium Carbonate, 5%, obtained by grinding.

Are any of the ingredients listed above irradiated?:
If yes, which ones (specify the type of irradiation also):
YES
NO
 Are all the ingredients listed above present in the appendix IV of the Standard?
YES
NO
If no, specify which ones:
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F349(GC)env03
ECOCERT Greenlife
10/03/2010
 Must these ingredients be labelled as nanoparticles on the cosmetic products
according to the Cosmetic directive definition?
YES
NO
If yes, which ones? :
D Synthetic origin ingredients:
List here all ingredients from synthetic origin present in your raw material, and their
percentage:
- Example: Sodium Benzoate, 0.1%.
-
3. Additives :
 Present preservatives (names, origins, manufacturing processes and content (%) :
 Present antioxidants (names, origins, manufacturing processes and content (%) :
 Present solvents (names, origins, manufacturing processes and content (%) :
 Other additives (names, origins, manufacturing processes and content (%) :
4. Secondary constituents and impurities :
Indicate for each of the following constituents if it could be contained in the product (entering in
the composition or sub product), if there is no data, indicate « ? »

1.4-Dioxane:
YES
NO
?

Ethylene oxide:
YES
NO
?

Propylene oxide:
YES
NO
?

Monomers:
YES
NO
?

Free amines :
 Amidoamine (>0,5%):
 Monoethanolamine (>0,5%):
YES
YES
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Any reproduction whether in whole or in part of this document, without written consent from ECOCERT is illegal.
NO
NO
?
?
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F349(GC)env03
ECOCERT Greenlife
10/03/2010

Heavy metals (cadmium, mercury, antimony, arsenic, chromium, cobalt, nickel,
lead, silver) concentration > 10 ppm :
YES
NO
?

Pesticides (-, -, -HCH, DDT, DDE, dichlofenthion, PCBs)
YES
NO
?

Aromatic hydrocarbons:
?

Other residues or impurities, specify :
YES
NO
III Environmental and toxicology data:
1. General :
 Have you evaluated and established a procedure for limiting accident risks (human
and environmental
YES
NO
If yes, please detail these measures:

Have you evaluated and established a procedure for the management of waste
production (recycling and others) in the manufacturing of this raw material or for
your manufacturing plant in general
YES
NO
If yes, please detail these measures:

Have you evaluated and established a procedure for energy economy in the
manufacturing of this raw material or for your manufacturing plant in general?:
YES
NO
If yes, please detail these measures:
This document is property of ECOCERT.
Any reproduction whether in whole or in part of this document, without written consent from ECOCERT is illegal.
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F349(GC)env03
ECOCERT Greenlife
10/03/2010
2. Toxicology data :

HET-CAM test:

Data concerning skin irritation :

Allergenic agents presence :

Mutagenic agents presence :
3. Environmental data : (must be filled in for each chemically processed ingredients)

Biodegradability OCDE series 301 :

Water toxicity (bacteria, algae, daphnia, fish) :
I undersigned,
, representing the company,
questionnaire is correct.
Issued in
, on the
, declare that the information given in this
.
Obligatory signature (preceded by the mention « read and approved »)
This document is property of ECOCERT.
Any reproduction whether in whole or in part of this document, without written consent from ECOCERT is illegal.
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