General - Kodak

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					0%      HSE Supplier Declaration Form (DF)
     Revision Date: November 30, 2011


     This form is used to document compliance to Kodak's Health, Safety, and Environmental Specifications for Products, Parts and Packaging (EKSP-2285, Version 2). The Supplier is
     expected to verify conformance, regardless of production location, and is responsible for contacting their suppliers to ensure accurate and complete information is provided to Kodak.
        Instructions:
        1) Review EKSP-2285 to accurately complete this form. The specification can be found by
           clicking the link to the right.
        2) Use either the tab key or right arrow to navigate the cells in this form.                                                                                            www.kodak.com/go/hsesupplier
        3) The Supplier must notify Kodak, by sending an email to ww-mcd@kodak.com, whenever
           product, process, material or regulatory changes result in changes to the declaration form.

                         Kodak Information                                                                                                                   Supplier Information
  Contact Name:                     DF Process Team                     Company Name:
0 Telephone Number:                 585-722-5994                        Contact Name:
0 Email:                                ww-mcd@kodak.com                Telephone Number:
0 Request Date:                                                         Email:


     I certify that I am authorized to complete this Declaration Form on behalf of my company. I also certify that my company has implemented processes to ensure the accuracy of the data provided for the products we supply and
     methods to verify and audit the information acquired through our supply chain, as necessary.

  In addition, I certify that my company has obtained and will maintain any necessary approvals and authorizations of regulatory agencies and other government organizations to manufacture in and export from the country of
  manufacture.
0                                                                             Certified By:
0                                                                                     Title:
0                                                                                     Date:




         Kodak Part #                   Item Description                      Supplier part #                         Declaration Type                                                    Comments                               PAD No. (Kodak use only)
                                                                                                                       Product Level
                                                                                                                       Product Level
                                                                                                                       Product Level




     Place an x below for each product type provided to Kodak and answer the questions that apply.
                                                                                                                                                                                **For a current list of EU RoHS exemptions go to
                            Electrotechnical Products                                                  Complete Section A
                                                                                                                                                                                http://www.bis.gov.uk/assets/bispartners/nmo/docs/rohs/exemptions/all%20current%20exemptions%2014
                            Batteries (including embedded batteries)                                   Complete Section AA                                                      %20sept%202011.pdf

                            Articles                                                                   Complete Section B
                            Chemicals                                                                  Complete Section C
                            Packaging                                                                  Complete Section D


                            The following questions pertain to Electrotechnical Products.
                            Devices that require alternating or direct electric current to operate. Also applies to items that are formed to a specific
                            shape or design which are intended to be incorporated into an equipment product and may or may not have a power
                            source. This includes, but is not limited to, sensors, hardware components, printed circuit boards, batteries, cables, cords,   EKSP-2285,
                            One-Time-Use (OTU) camera and body labels, paper trays and sub-components used to assemble equipment products                   version 2 section
     SECTION A              and/or systems.                                                                                                                 reference (link)    Response                          Comments
                            Does your company have a documented process to ensure that tantalum, tin, tungsten and gold in
                            the products that you provide to Kodak do not directly or indirectly finance or benefit armed groups
                            that are perpetrators of serious human rights abuses in the Democratic Republic of the Congo
                            (DRC) or an adjoining country as defined by the Conflict Metals Map published by the U.S.
              A1            Secretary of State?                                                                                                                 3.1.3
              A2            Do the items contain any conflict metals? (if yes, identify conflict metals)                                                         5.1
              A3            Are all items compliant with EU RoHS? (if no, describe part and substance)                                                           5.1
                            Do any items use an EU RoHS exemption for Cadmium? (if yes, describe part and identify the EU
              A4            RoHS exemption number(s)**)                                                                                                           5.1
                            Do any items use an EU RoHS exemption for Chromium (VI)? (if yes, describe part and identify the
              A5            EU RoHS exemption number(s)**)                                                                                                        5.1
                            Do any items use an EU RoHS exemption for Lead? (if yes, describe part and identify the EU RoHS
              A6            exemption number(s)**)                                                                                                                5.1
                            Do any items use an EU RoHS exemptions for Mercury? (if yes, describe part and identify the EU
              A7            RoHS exemption number(s)**)                                                                                                           5.1
                            Do any items use an EU RoHS exemption for PBB? (if yes, describe part and identify the EU RoHS
              A8            exemption number(s)**)                                                                                                                5.1
                            Do any items use an EU RoHS exemption for PBDE? (if yes, describe part and identify the EU
              A9            RoHS exemption number(s)**)                                                                                                           5.1
              A10           Do any items contain intentionally added mercury? (if yes, describe part and amount)                                                  5.1
              A11           Are all parts in the product below the threshold of 600 ppm for lead? (if no, describe part)                                          5.1
              A12           Do any items, other than wire insulation, contain PVC/PVDC? (if yes, describe)                                                        5.1
                            Do any items contain restricted materials above the thresholds described in Appendix A, Table 1 of
              A13           EKSP-2285? (if yes, describe part, substance and amount.)                                                                            5.1
              A14           Do any items contain SVHCs above 0.1%? (if yes, describe part and substance)                                                         5.2
              A15           Do all plastic parts greater than 25 grams have the ISO mark? (if no, describe part)                                                5.4.1
              A16           Do all plastic assemblies meet the manual separation requirement? (if no, describe)                                                 5.4.2
              A17           Do all plastic parts meet the single resin requirement? (if no, describe)                                                           5.4.3
              A18           How many batteries are embedded in the product and/or shipped with the product?                                                      5.5
              A19           Do any items contain composite wood? (if yes, describe)                                                                              5.6
              A20           Identify the sound pressure levels at operator position from the drop down menu.                                                    5.7.3
             Does the product generate any emissions during normal conditions of use or foreseeable misuse? (if
      A21    yes, identify substance(s) and provide available emission data)                                                                      5.7.6
      A22    Do all printed material meet the paper requirements?                                                                                 5.7.7


                                                                                                                                             EKSP-2285,
             The following questions pertain to Batteries. (including batteries embedded in electrotechnical                                 version 2 section
Section AA   products)                                                                                                                       reference (link)    Response   Comments
             Does your company have a documented process to ensure that tantalum, tin, tungsten and gold in
             the products that you provide to Kodak do not directly or indirectly finance or benefit armed groups
             that are perpetrators of serious human rights abuses in the Democratic Republic of the Congo
             (DRC) or an adjoining country as defined by the Conflict Metals Map published by the U.S.
      AA1    Secretary of State?                                                                                                                  3.1.3
      AA2    Do the items contain any conflict metals? (if yes, identify conflict metals)                                                          5.1
      AA3    Does the battery contain mercury above 1000 ppm at the homogeneous level?                                                             5.1
      AA4    Does the battery contain lead above 1000 ppm at the homogeneous level?                                                                5.1
      AA5    Does the battery contain cadmium above 100 ppm at the homogeneous level?                                                              5.1
      AA6    Does the battery contain chromium (VI) above 1000 ppm at the homogeneous level?                                                       5.1
      AA7    Does the battery contain PBB above 1000 ppm at the homogeneous level?                                                                 5.1
      AA8    Does the battery contain PBDE above 1000 ppm at the homogeneous level?                                                                5.1
      AA9    If a button cell battery, does the battery contain intentionally added mercury?                                                       5.1
      AA10   Does the battery contain mercury above 1 ppm by weight of battery?                                                                    5.1
      AA11   Does the battery contain cadmium above 5 ppm by weight of battery?                                                                    5.1
      AA12   Does the battery contain lead greater than 40 ppm by weight of battery?                                                               5.1
             Does the battery casing contain polyvinyl chloride (PVC) or polyvinylidene dichloride (PVDC)? (if
      AA13   yes, provide amount)                                                                                                                  5.1
      AA14   Does the battery contain perchlorate?                                                                                                 5.1
      AA15   Does the battery contain SVHCs above 0.1%? (if yes, identify substance)                                                               5.1
      AA16   Identify the model number                                                                                                             5.5
      AA17   Identify the battery chemistry                                                                                                        5.5
      AA18   Identify the battery shape                                                                                                            5.5
      AA19   Identify the voltage                                                                                                                  5.5
      AA20   Identify the Watt hours                                                                                                               5.5
      AA21   Provide the weight of one battery                                                                                                     5.5

             The following questions pertain to Articles.
             Manufactured items that are formed to a specific shape or design, which have an end-use function in whole or in part
             dependent on their shape or design, but does not require alternating or direct electric current to operate. Examples of
             Articles include film, paper, film or paper base, compact discs, aluminum printing plates, mugs, clothing, photo gifts,
             camera bags, straps and tripods.

             Articles also include Packaging-Related Product Components – A part or constituent of the sales unit that is essential to
             the use of the product for its intended purpose or application. Examples of packaging-related product components include:
             ink cartridges, ink tanks, toner bottles, 35 mm magazines, film cassettes, film cartridges, film cartridge or cassette labels, EKSP-2285,
             video tape cassette labels, film paster and after-exposure labels, film spool or reels, long term storage boxes (microfilm,    version 2 section
SECTION B    prints, transparencies), plastic compact disc cases, print wallets and video storage containers.                               reference (link)     Response   Comments
             Does your company have a documented process to ensure that tantalum, tin, tungsten and gold in
             the products that you provide to Kodak do not directly or indirectly finance or benefit armed groups
             that are perpetrators of serious human rights abuses in the Democratic Republic of the Congo
             (DRC) or an adjoining country as defined by the Conflict Metals Map published by the U.S.
       B1    Secretary of State?                                                                                                                  3.1.3
       B2    Do the items contain any conflict metals? (if yes, identify conflict metals)                                                          6.1
       B3    Do any items contain PVC/PVDC? (if yes, describe)                                                                                     6.1
             Do any items contain restricted materials above the thresholds described in Appendix B of EKSP-
       B4    2285? (if yes, describe part, substance and amount.)                                                                                  6.1
       B5    Do any items contain SVHCs above 0.1%? (if yes, describe part and substance)                                                         6.2.1
       B6    Does the item require a California Proposition 65 label?                                                                             6.2.2
             Are there any components listed on 40CFR 261.24, Table 1 (hazardous waste)? (if yes, identify and
       B7    provide TCLP results)                                                                                                                6.2.3
             Does any item contain intentionally manufactured particles that have at least one dimension of up to
      B8     500 nanometers? (if yes, describe and provide size distribution information)                                                         6.2.4
      B9     Do any items contain biocides? (if yes, describe)                                                                                     6.4
      B10    Do all paper products and printed material meet the paper requirements?                                                               6.5
      B11    Do all plastic parts greater than 25 g have the ISO mark? (if no, describe part)                                                     6.6.1
      B12    Do all plastic assemblies meet the manual separation requirement? (if no, describe)                                                  6.6.2
      B13    Do all plastic parts meet the single resin requirement? (if no, describe)                                                            6.6.3
      B14    Do any items contain composite wood? (if yes, describe)                                                                               6.7
             Does the product generate any emissions during normal conditions of use or foreseeable misuse? (if
      B15    yes, identify substance(s) and provide available emission data)                                                                       6.9

             The Following questions pertain to Chemicals.
             Products or raw materials made of organic or inorganic substances with a distinct molecular composition, which can be a
             solid, liquid or gas. Chemicals may be individual chemicals or mixtures. Chemicals are typically consumed during use.           EKSP-2285,
             Examples of chemical products include toners, inks, photochemicals and alcohol cleaning wipes. Examples of raw                  version 2 section
SECTION C    materials include solvents, polymers and chemical raw materials.                                                                reference (link)    Response   Comments
             Does your company have a documented process to ensure that tantalum, tin, tungsten and gold in
             the products that you provide to Kodak do not directly or indirectly finance or benefit armed groups
             that are perpetrators of serious human rights abuses in the Democratic Republic of the Congo
             (DRC) or an adjoining country as defined by the Conflict Metals Map published by the U.S.
       C1    Secretary of State?                                                                                                                  3.1.3
       C2    Do the items contain any conflict metals? (if yes, identify conflict metals)                                                          7.1
             Do any items contain restricted materials above the thresholds described in Appendix C of EKSP-
       C3    2285? (if yes, describe part, substance and amount.)                                                                                  7.1
             Are there any components listed on 40CFR 261.33(hazardous waste)? (if yes, identify and provide
       C4    weight percent in product)                                                                                                           7.2.1
       C5    Provide flashpoint, pH, and reactivity evaluation as defined in 40CFR 261.23                                                         7.2.1
            Does any item contain intentionally manufactured particles that have at least one dimension of up to
     C6     500 nanometers? (if yes, describe and provide size distribution information)                                                   7.2.2
     C7     Are all components on TSCA (US)? (if no, describe)                                                                              7.4
     C8     Are all components on AICS (Australia)? (if no, describe)                                                                       7.4
     C9     Are all components on DSL (Canada)? (if no, describe)                                                                           7.4
     C10    Are all components on the NDSL (Canada)? (if no, describe)                                                                      7.4
     C11    Are all components on Providence of Ontario inventory? (if no, describe)                                                        7.4
     C12    Are all components on IECSC (China)? (if no, describe)                                                                          7.4
     C13    Are all components on ENCS (Japan)? (if no, describe)                                                                           7.4
     C14    Are all components on ECL (Korea)? (if no, describe)                                                                            7.4
     C15    Are all components on NZIoC (New Zealand)? (if no, describe)                                                                    7.4
     C16    Are all components on PICCS (Philippines)? (if no, describe)                                                                    7.4
     C17    Are all components on Switzerland inventory? (if no, describe)                                                                  7.4
     C18    Are all components on Turkey inventory? (if no, describe)                                                                       7.4
     C19    Are all components on Taiwan inventory? (if no, describe)                                                                       7.4
     C20    Are all components on EINECS European Union (EU)? (if no, describe)                                                             7.4
     C21    Has your company preregistered or registered all items under REACH? (if exempt, explain)                                        7.5
     C22    Are the items manufactured in the EU?                                                                                           7.5
     C23    Will your company's "Only Representative" agree to include Kodak volumes/use?                                                   7.5
     C24    Do any items contain biocides? (if yes, describe)                                                                               7.6
            Does the product generate any emissions during normal conditions of use or foreseeable misuse? (if
     C25    yes, identify substance(s) and provide available emission data)                                                                  7.8
     C26    Do all printed material meet the paper requirements? (if no, describe)                                                           7.9



            The following questions pertain to Packaging.
            Any material intended to be used for the containment, protection, handling, delivery and presentation of goods from raw
            materials to processed goods from the producer to the user or consumer as defined by the European Parliament and
            Council Directive 94/62/EC on Packaging and Packaging Waste. Packaging may be classified as primary packaging,
            grouped or secondary packaging, and transport or tertiary packaging. Examples of packaging include: cartons, crates,       EKSP-2285,
            pails, trays, bags, pallets, pallet collars, drums, load boards, skids, dunnage, interior or exterior blocking, bracing,   version 2 section
SECTION D   cushioning, weatherproofing, exterior strapping, stretch wrapping, coatings, closures, inks, adhesives, and labels.        reference (link)    Response   Comments
      D1    Does packaging contain PVC/PVDC? (if yes, describe)                                                                              8.1
            Are any items above the material restriction thresholds described in Appendix D of EKSP-2285? (if
     D2     yes, describe part, substance and amount.)                                                                                      8.1
     D3     Do any items contain SVHCs above 0.1%? (if yes, describe part and substance)                                                    8.2
     D4     Do all items made of plastic have the SPI mark? (if no, describe part)                                                          8.3
     D5     Do all items made of paper comply with paper requirements? (if no, describe)                                                    8.4
     D6     Do all solid wood packaging materials comply with ISPM-15?                                                                      8.5
     D7     Does packaging meet the separable packaging requirement? (if no, describe)                                                      8.6
     D8     Do all items comply with regulatory requirements in the US? (if no, describe)                                                  8.7.2
     D9     Do all items comply with regulatory requirements in the EU? (if no, describe)                                                  8.7.3
     D10    Do all items comply with regulatory requirements in the China? (if no, describe)                                               8.7.4
     D11    Do all items comply with regulatory requirements in the Japan? (if no, describe)                                               8.7.5
     D12    Do all items comply with regulatory requirements in the South Korea? (if no, describe)                                         8.7.6

				
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