TEST REQUEST FORM
TOY AND JUVENILE PRODUCTS
QUOTATION REQUIRED BEFORE TESTING Please note that quotation fees may apply for this service. Testing is initiated upon receipt of signed quotation
with complete information and samples.
Submitting Company:
HAYNEEDLE, INC.
Purchase Order No.:
Address
9394 WEST DODGE ROAD, SUITE 300
City
OMAHA
State
NE
Zip
68114-3319
Report Recipient : JESSICA GARCIA
Phone:
402-715-3308
Fax :
E-mail : JGARCIA@HAYNEEDLE.COM
Report cc :
CHRISTINE TVRDIK
Phone:
402-715-3229
Fax :
E-mail :
Invoice will state the above report recipient. Please advise if different:
Invoice Recipient :
Phone:
Fax :
Sample Description:
Manufacturer / Vendor:
SKU / UPC:
Item / Style #:
CTVRDIK@HAYNEEDLE.COM
E-mail :
# of Samples Submitted:
(7 samples preferred)
Return Samples?
No
*List courier & acct #:
Country of Origin:
Country of Distribution:
Yes*
CPSIA General Conformity Certificate / Children’s Product Certificate
CPSIA Applicable rules review and GCC/CPC under BVCPS GCC/CPC services scope
Please provide name, full mailing address, e-mail address and telephone number of the person maintaining test records in support of the certification.
Name of Importer of Record or
Domestic Manufacturer:
Mailing Address/ Tel No.:
Date of Manufacture (MM/DD/YY):
(Remark: This importer of record/domestic manufacturer information is required
for CPSIA’s General Conformity Certificate)
Place of Manufacture (City/Province/Country):
SERVICE REQUIRED:
(Check One)
Regular (7 business days)
Next 3 Day (40% surcharge)
Next 2 Day (50% surcharge)
Next Business Day* (100% surcharge)
Express (100% surcharge for extended time tests)*
Same Business Day* (175% surcharge)
* - Sample including completed paperwork for rush services must be in receipt of BV by 10:30am required.
TESTING REQUSTED (Please check appropriate box(es))
Labeled age will be used for testing if no instruction is given.
State age grade to be used for testing:
Age Grade determined by BVCPS
Age Grade Evaluation Only
Retest (selected tests only), please specify tests to be performed:
Previous Report Number (mandatory for retests):
Retest (full testing)
PROTOTYPE SAMPLE- DO NOT PERFORM ANY DESTRUCTIVE TESTING Please label the package as a prototype with no destructive testing performed.
US CPSC FHSA Regulations
16 CFR 1500 Mechanical Hazards
16 CFR 1500.44 (Flammability of Solids)
US FDA 21 CFR 175-177 Solvent Extractives
*COMPLETE FDA FOOD SAFETY FORM
US ASTM F963 Standard
Mechanical Hazards
Flammability
Heavy Metals
Nitrosamines
Labeling
Illinois Lead Content
Illinois Lead Content
Micro/Toxicity
USP 51 – Preservative Effectiveness
USP 61 – Microbial Limits
LHAMA – ASTM D-4236*
*COMPLETE INGREDIENT LIST FORM
Tox. Risk Assessment (TRA)*
Country
US
CN
EU
*COMPLETE INGREDIENT LIST FORM, please
note each country evaluated for TRA is a separate
charge
California Prop 65
Children’s Jewelry
Phthalates
Lead in PVC
Misc Testing
FPLA/UPLR Labeling
Dimethy Fumarate
FCC Compliance
BPA
XRF
Additional US Flammability
16 CFR 1611 – Vinyl
CPAI – 75 – Sleeping Bags
CPAI - 84 – Tents
Cal. TB 117 – Upholstered Furniture
Juvenile Products
16 CFR 1508 & ASTM F1169–Full Size Cribs
16 CFR 1509 & ASTM F406–Non Full Size Cribs
16 CFR 1511– Pacifiers
16 CFR 1512–Bicycles
16 CFR 1513 & ASTM F1427–Bunk Beds
16 CFR 1203 – Bicycle Helmets
US CPSIA 2008
- Lead
CPSIA Total lead content in substrate*
Composite up to 3 colors?
Yes
No
CPSIA Total lead content in surface coating*
Composite up to 3 colors?
Yes
No
*Requires FHSA Use and Abuse testing to
determine accessibility
CPSIA Total lead content in Children's Metal
Jewelry (300ppm)
- Material composition documentation needed for
each component.
-Phthalates (Bill of materials required)
CPSIA BBP/DBP/DEHP
Composite up to 3 colors?
Yes
CPSIA DNOP/DINP/DIDP content
Composite up to 3 colors?
Yes
CPSIA Tracking Label Evaluation**
Location of Production on Package (city/country)
No
Location of Production on Product (city/country)
No
Date of Production on Package (month/Year)
Date of Production on Product (month/Year)
**Please provide explanation of tracking label coding
system
Canada CHPA Regulations
Mechanical Hazards
Flammability
Heavy Metals
Labeling/CPLR
European Requirements
EN 71 Pt. 1 – Mech. Hazards
EN 71 Pt. 1 – Mech. Hazards with Labeling
EN 71 Pt. 2 – Flammability
EN 71 Pt. 3 – Heavy Metals
Phthalates (2005/84/EC)
Cadmium Content (91/338/EEC)
Other Tests/Instructions: Do not assemble products. Please perform composite testing across all styles – do not test each style individually.
Date
Authorized Signature
When submitting this form electronically, by typing your signature and/or inserting a digital signature, you are acknowledging and
agreeing to the Conditions of Testing set forth on Page 2. When submitting a hard copy, please include a hand signed signature.
Please include both pages of the completed test request form with each carton of samples and forward to:
Bureau Veritas Consumer Products Services, Inc.; 100 Northpointe Parkway, Buffalo, New York 14228-1884
Last updated 1/12/2011
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TEST REQUEST FORM
TOY AND JUVENILE PRODUCTS
Tel: (716) 505-3300 Fax: (716) 505-3301 cps.bureauveritas.com
------------------------------------------------FOR LABORATORY INTERNAL USE ONLY----------------------------------------------Date Received: _________________Received by: ______________ Sample #: _________________________
BUF-FRM-00XXX, Rev 1
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