Kodak Health, Safety and Environment Product Specifications Declaration Form DF-2008 Version: 2.00 7.00 This form is used to document compliance to Eastman Kodak Company Health, Safety and Environmental Specifications for Equipment, Packaging, Articles and Chemical Products or their comp purchased or used for Kodak products. As a Kodak supplier, you can send Declaration Forms to sub-suppliers, however, you should combine into one declaration form submitted to Kodak. Instructions: You will need to refer to the appropriate specifications (EKSP-1636, 1594 & 1614) to accurately complete this form. The specifications can be found by clicking the link to the right. If you would like to declare other parts your company supplies to Kodak on this declaration add them to the table below. This form holds a maximum of 30 parts. Mandatory fields are highlighted in blue. Complete information in all workbook tabs and click the "Certify, Save & Submit" button to return to Kodak. The form will check for incomplete items when you when you click "Certify, Save & Submit". NOTE: Use either the tab key or right arrow to navigate the cells in this form. www.kodak.com/go/hsesupplier. Kodak Information Supplier Information Contact Name: Melanie Marshall Company Name: Supplier Telephone Number: (585) 722-5994 Contact Name: Email: email@example.com Telephone Number: Request Date: 17 Dec 2009 12:51:33:257 Email: I certify that I am authorized to declare this Material Composition Declaration Form on behalf of my company; that this product was produced by my company. I also certify that if this product wa using parts from another company, that I am responsible for the accuracy of information provided. 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 an from the country of manufacture. Certified By: Title: Date: Click this button to add a new part number. Add New Part Number Supplier Part Numbers requiring Material Composition Declaration: Kodak Part # Item Description Supplier part # Product Type Comments 1e Equipment 1e Equipment 2a Article 2a Article 3c Chemical 3c Chemical 4p Packaging component 4p Packaging Component 5p All packaging provided for a product 5p Packaging Subassembly Remember to complete all tabs in the workbook before clicking "Certify, Save & Submit". Certify, Save & Submit Certify, Save & Submit When you click the button the form will check for missing data and inform you to fix any errors before submitting. MATERIALS REQUIRING DECLARATION FOR ALL PRODUCTS General Instructions: Answer yes or no to the question "Is the material of concern known to be present?" If yes report either the weight and unit of (UoM), or the concentration (PPM). Provide a description of use and answer yes or no to the question "Is use intentional?". The button "Autofill all - clicked to automatically answer "No" to the question "Is the material of concern known to be present?". This button will not work if macros are disab For Packaging Product Types: For the Heavy Metals material of concern, supplier must report concentration (ppm) , it is optional to provide weig appropriate unit of measure (UoM). For Equipment Product Types: The RoHS six materials are identified with dual asterisks (**), suppliers must report the worst case concentration homogeneous material level. See HSE Product Specification EKSP-1614 for a definition of homogeneous material level. It is optional to provide the of the substance in the item. Is the material Autofill all - No of concern known to be Part No. Product Type Category Name present? Weight UoM PPM Describe Use 1e Equipment Asbestos Azo Colorants which form certain aromatic 1e Equipment amines 1e Equipment Cadmium/Cadmium Compounds** 1e Equipment Cadmium/Cadmium in Batteries Hexavalent Chromium/Hexavalent Chromium 1e Equipment Compounds (Cr+6)** 1e Equipment Lead/Lead Compounds** 1e Equipment Lead/Lead Compounds in Batteries 1e Equipment Mercury/Mercury Compounds** Mercury/Mercury Compounds in Batteries 1e Equipment Ozone Depleting Substances- Class I CFCs, 1e Equipment HBFCs Ozone Depleting Substances- Class II 1e Equipment HCFCs 1e Equipment Polybrominated biphenyls (PBBs)** Polybrominated diphenyl ethers (PBDEs)** 1e Equipment 1e Equipment Other Brominated Flame Retardants Polychlorinated Biphenyls (PCBs) and 1e Equipment specific substitutes 1e Equipment Polychlorinated Terphenyls (PCTs) Polychlorinated Naphthalenes (more than 3 1e Equipment chlorine atoms) Polyvinyl Chloride (PVC) Polyvinylidene 1e Equipment dichloride (PVDC) 1e Equipment PVC and PVDC in the battery casing. 1e Equipment Radioactive Substances 1e Equipment Short Chained Chlorinated Paraffins Tributyl Tin (TBT) and Triphenyl Tin (TPT) 1e Equipment 1e Equipment Tributyl Tin Oxide (TBTO) 1e Equipment Natural rubber latex 1e Equipment PFOS, PFOA, or related substances 1e Equipment Beryllium Oxide 1e Equipment Nickel (external applications only) 1e Equipment Phthalates (DEHP, DBP, BBP) 1e Equipment Phthalates (DINP, DIDP, DNOP) 1e Equipment Formaldehyde 1e Equipment Perchorates Fluorinated Greenhouse Gases (HFC, PFC, 1e Equipment SF6) Phenol,2-(2H-benzotriazol-2-yl)-4,6-bis(1,1- 1e Equipment dimethylethyl) Azo Colorants which form certain aromatic 2a Article amines 2a Article Cadmium/Cadmium Compounds Hexavalent Chromium/Hexavalent Chromium 2a Article Compounds (Cr+6) 2a Article Lead/Lead Compounds 2a Article Mercury/Mercury Compounds 2a Article Formaldehyde 2a Article Certain Phthalates Ozone Depleting Substances- Class I CFCs, 2a Article HBFCs Ozone Depleting Substances- Class II 2a Article HCFCs 2a Article Polybrominated biphenyls (PBBs) Polybrominated diphenyl ethers (PBDEs) 2a Article Brominated Flame Retardants (other than 2a Article PBB or PBDE) Polyvinyl Chloride (PVC) and Polyvinylidene 2a Article dichloride (PVDC) 2a Article PFOS, PFOA, or related substances 2a Article Bisphenol A (BPA) Azo Colorants which form certain aromatic 3c Chemical amines 3c Chemical Cadmium/Cadmium Compounds Hexavalent Chromium/Hexavalent Chromium 3c Chemical Compounds (Cr+6) 3c Chemical Lead/Lead Compounds 3c Chemical Mercury/Mercury Compounds 3c Chemical Formaldehyde 3c Chemical Certain Phthalates Ozone Depleting Substances- Class I CFCs, 3c Chemical HBFCs Ozone Depleting Substances- Class II 3c Chemical HCFCs 3c Chemical Polybrominated biphenyls (PBBs) Polybrominated diphenyl ethers (PBDEs) 3c Chemical Brominated Flame Retardants (other than 3c Chemical PBB or PBDE) Polyvinyl Chloride (PVC) and Polyvinylidene 3c Chemical dichloride (PVDC) 3c Chemical PFOS, PFOA, or related substances 3c Chemical Bisphenol A (BPA) Azo Colorants which form certain aromatic 4p Packaging amines Ozone Depleting Substances- Class I CFCs, 4p Packaging HBFCs Ozone Depleting Substances- Class II 4p Packaging HCFCs 4p Packaging Polybrominated biphenyls (PBBs) Polybrominated diphenyl ethers (PBDEs) 4p Packaging Brominated Flame Retardants (other than 4p Packaging PBB or PBDE) Polyvinyl Chloride (PVC) Polyvinylidene 4p Packaging dichloride (PVDC) 4p Packaging PFOS, PFOA, or related substances Heavy Metals (Cadmium, Chromium(Cr+6), 4p Packaging Lead, Mercury) Azo Colorants which form certain aromatic 5p Packaging amines Ozone Depleting Substances- Class I CFCs, 5p Packaging HBFCs Ozone Depleting Substances- Class II 5p Packaging HCFCs 5p Packaging Polybrominated biphenyls (PBBs) Polybrominated diphenyl ethers (PBDEs) 5p Packaging Brominated Flame Retardants (other than 5p Packaging PBB or PBDE) Polyvinyl Chloride (PVC) Polyvinylidene 5p Packaging dichloride (PVDC) 5p Packaging PFOS, PFOA, or related substances Heavy Metals (Cadmium, Chromium(Cr+6), 5p Packaging Lead, Mercury) FOR CHEMICAL AND ARTICLE PRODUCTS 1. Does this product contain other known, probable or potential carcinogens, mutagens or reproductive toxicants? If yes, declare below. Please select the chemical or article part number that contains the compound. Level Associated with Compound CAS No. (ppm) Part Number Describe Use 2. Does this product contain materials with other health concerns? If yes, declare below. Please select the chemical or article part number that contains the compound. Level Associated with Compound CAS No. (ppm) Part Number Describe Use 3. Does this product contain materials with environmental concerns? If yes, declare below. Please select the chemical or article part number that contains the compound. Level Associated with Compound CAS No. (ppm) Part Number Describe Use 4. Does this product contain potent sensitizers? If yes, declare below. Please select the chemical or article part number that contains the compound. Level Associated with Compound CAS No. (ppm) Part Number Describe Use 5. Does this product contain Substances of Very High concern (SVHC)? If yes, declare below. Please select the chemical or article part number that contains the compound. Associated with Compound CAS No. Weight Percent Part Number Describe Use 6. Does this product generate or emit airborne emissions during normal conditions of use or foreseeable misuse? If yes, declare below. Please select the chemical or article part number that contains the compound. Level Associated with Compound CAS No. (ppm) Part Number Describe Use General Comments FOR CHEMICAL AND ARTICLE PRODUCTS Instructions: Indicate whether all components of chemical products or substances released from articles are included in the following countries' chemical control inventories. Blue highlighted items are mandatory. Have you Will you ensure Are substances Exempt from Part appointed an Kodak's use / released from REACH preregistered or only volumes are Article during United States Canada Province of Ontario Philippines Describe notifications if preregistration or Manufactured in registered under representative included in the Part No. use? (TSCA) Australia (AICS) Canada (DSL) (NDSL) Canada China Korea (ECL) Japan (METI) (PICCS) Switzerland New Zealand applicable. registration? If exempt, explain why? the EU? REACH? for REACH? registration? 2a 3c Instructions: Answer questions for each Article and Chemical listed below. The dropdown choices distinguish between "chemical", "article" and "chemical & article" product types. An example of a single part number being a "chemical & article" product type is an ink cartridge full of ink. Blue highlighted items are mandatory. Biocides Mutagenicity Testing Hazardous Waste Toy Safety Nanoparticles Has the chemical Upon disposal is Describe and/or Does the product contain Is biocide Is biocide Is biocide product been Has each dye or Have any other this product provide Has the product been intentionally manufactured Does the product approved for approved for approved for tested for pigment within the components considered a hazardous tested against toy safety Are the results particles that have at least contain a this use in US this use in this use in the mutagenicity product been tested What are the been tested for What are the hazardous waste migration protocol EN71- below regulatory one dimension of 1 to 100 Part No. biocide? (FIFRA)? Canada (PCA)? EU (BPD)? (AMES test)? Results of test? for mutagenicity? results? mutagenicity? results? waste? classification. 3 or ASTM F963? limits? nanometers? Describe use. 2a 3c FOR CHEMICALS ONLY FOR ARTICLES ONLY List applicable Identify the Identify the Identify the Forest product safety mill(s) that percentage of Certification standards that Are all plastic Have you sourced all recycled pulp or Scheme (I.e. FSC, this product parts >25 g Weight of plastic Total weight of provided Kodak Identify the composite paper material SFI) for the pulp meets (i.e. marked per ISO used in product product % recycled part number Product Type Provide pH with a SDS? support wood. used. source. flammability etc)? Standard 11469? (in grams) (in grams) plastic 2a Article 3c Chemical FOR EQUIPMENT PARTS OR PRODUCTS 0 0 Does this product contain Substances of Very High concern (SVHC)? If yes, declare below. Please select the part number containing this compound. Weight Associated with Compound CAS No. Percent Part Number Describe Use 0 Does this product generate or emit airborne emissions during normal conditions of use or foreseeable misuse? If yes, declare below. Please select the part number containing this compound. Level Associated with Compound CAS No. (ppm) Part Number Describe Use Noise Plastic Marking Composite Wood Nanoparticles EU RoHS Plastic Composition Does the product contain Are all plastic parts intentionally manufactured Does the product >25 g marked per Identify the mill(s) particles that have at least one Weight of plastic Total weight of meet the ISO-7779 ISO Standard that sourced all dimension of 1 to 100 EU RoHS EU RoHS used in product product % recycled 1 Part Number standard for noise? 11469? composite wood. nanometers? Describe use. Declaration Exemption (in grams) (in grams) plastic nano valid all valid 0 1e 0 0 Batteries Instructions: For each equipment part number containing a battery identify the battery type, chemistry, size/shape, voltage, quantity of each type, weight, world wide transportation classification and if percholorate is present. Weight per WW transportation Percholorate Parent part number Battery type Chemistry Size / Shape Voltage Quantity of this type battery (g) classification present? FOR PACKAGING SUBASSEMBLIES AND PACKAGING COMPONENTS Instructions: Complete the table by filling in data in the cells shaded blue. For packaging subassembly items the answers must represent all of the subassembly's components. Comments pertaining to the item can be provided on the General tab. For the products indicated below, does the sub assembly comply with the requirements for the following regions: REACH For Rigid Plastic Containers For Paper For Solid or Composite Wood Does RPPC Identify the Forest Do you have the Does this product Does the use of plastic Is the RPPC contain at least Certification capability to supply Are your wood contain >0.1 meet the definition of a marked with the 25% post Scheme (I.e. FSC, wood packaging that packaging Supplier Part European South United weight % of Describe "Rigid Plastic Container" appropriate SPI consumer SFI) for the pulp meets the UN materials free of No. Component Description China Japan Union Korea States SVHC? use (RPPC)? code? recycled content? source. Standard ISPM-15? bark? 4p Packaging component 5p All packaging provided for a product Equipment tab EU RoHS Declaration EU RoHS Exemptions 1 - Item(s) does not contain RoHS restricted substances per definition 0 None Applicable 2 - Item(s) contains RoHS restricted substances above the limits per definition & is 1 Mercury compact fluorescent lamps not exceeding 5 not under exemption mg per lamp 3 - Item(s) does not contain RoHS restricted substances per definition except for selected 2-1 Mercury halophosphate straight fluorescent lamps exemptions for general purposes 10mg 4 - Item(s) is obsolete, no information is 2-2 Mercury triphosphate straight fluorescent lamps available normal lifetime 5 mg 5 - Item(s) is unknown, no information is 2-3 Mercury triphosphate straight fluorescent lamps available long lifetime 8 mg 3 Mercury straight fluorescent lamps for special purposes 4 Mercury Other Lamp types 5 Lead glass of cathode ray tubes, electronic components and fluorescent tubes 6-1 Lead Alloying Element in Steel up to 0.35% 6-2 Lead Alloying Element in Aluminium up to 0.4% 6-3 Lead Alloying Element in Copper up to 4% 7-1 Lead high melting temperature type solders (i.e. lead-based alloys containing 85% by weight or more lead) 7-2 Lead solders for servers, storage and storage array systems, network infrastructure equipment for switching, signalling, transmission as well as network management for telecommunication 7-4 Lead in electronic ceramic parts (e.g. piezoelectronic devices) 8 Cadmium and its compounds in electrical contacts and plating except for appliations banned under EU Directive 91/338/EEC amending directive 76/769/EEC relating to restrictions on the marketing and use of certain dangerous substances and preparations 9 Hexavalent chromium as an anti-corrosion of the carbon steel cooling system in absorption refrigerators 11 Lead used in compliant pin connector systems 12 Lead as a coating material for a thermal conduction module c-ring 13-1 Lead in optical and filter glass 13-2 Cadmium in optical and filter glass 14 Lead in solders consisting of more than two elements for the connection between the pins and the package of microprocessors with a lead content of more than 80% and less than 85% by weight 15 Lead in solders to complete a viable electrical connection between semiconductor die and carrier within integrated circuit Flip Chip packages 9a DecaBDE in polymeric applications 9b Lead in lead-bronze bearing shells and bushes 16 Lead in linear incandescent lamps with silicate coated tubes. 17 Lead halide as radiant agent in High Intensity Discharge (HID) lamps used for professional reprography applications. 18 Lead as activator in the fluorescent powder (1 % lead by weight or less) of discharge lamps when used as sun tanning lamps containing phosphors such as BSP (BaSi2O5:Pb) as well as when used as speciality lamps for diazo-printing reprography, lithography, insect traps, photochemical and curing processes containing phosphors such as SMS ((Sr,Ba)2MgSi2O7:Pb). 19 Lead with PbBiSn-Hg and PbInSn-Hg in specific compositions as main amalgam and with PbSn-Hg as auxiliary amalgam in very compact Energy Saving Lamps (ESL). 20 Lead oxide in glass used for bonding front and rear substrates of flat fluorescent lamps used for Liquid Crystal Displays (LCD). 21-1 Lead in printing inks for the application of enamels on borosilicate glass. 21-2 Cadmium in printing inks for the application of enamels on borosilicate glass. 22 Lead as impurity in RIG (rare earth iron garnet) Faraday rotators used for fibre optic communications systems. 23 Lead in finishes of fine pitch components other than connectors with a pitch of 0.65 mm or less with NiFe lead frames and lead in finishes of fine pitch components other than connectors with a pitch of 0.65 mm or less with copper lead frames. 24 Lead in solders for the soldering to machined through hole discoidal and planar array ceramic multilayer capacitors. 25 Lead oxide in plasma display panels (PDP) and surface conduction electron emitter displays (SED) used in structural elements; notably in the front and rear glass dielectric layer, the bus electrode, the black stripe, the address electrode, the barrier ribs, the seal frit and frit ring as well as in print pastes. 26 Lead oxide in the glass envelope of Black Light Blue (BLB) lamps. 27 Lead alloys as solder for transducers used in high- powered (designated to operate for several hours at acoustic power levels of 125 dB SPL and above) loudspeakers. 28 Hexavalent chromium in corrosion preventive coatings of unpainted metal sheetings and fasteners used for corrosion protection and Electromagnetic Interference Shielding in equipment falling under category three of Directive 2002/96/EC (IT and telecommunications equipment). EXPIRED 1st July 2007 29 Lead bound in crystal glass as defined in Annex I (Categories 1, 2, 3 and 4) of Council Directive 69/493/EEC 30 Cadmium alloys as electrical/mechanical solder joints to electrical conductors located directly on the voice coil in transducers used in high-powered loudspeakers with sound pressure levels of 100 dB (A) and more 31 Lead in soldering materials in mercury free flat fluorescent lamps (which e.g. are used for liquid crystal displays, design or industrial lighting) 32 Lead in seal frit used for making window assemblies for Argon and Krypton laser tubes 33 Lead in solders for the soldering of thin copper wires of 100 µm diameter and less in power transformers. 34 Lead in cermet-based trimmer potentiometer elements. 35 Cadmium in photoresistors for optocouplers applied in professional audio equipment until 31 December 2009. 36 Mercury used as a cathode sputtering inhibitor in DC plasma displays with a content up to 30 mg per display until 1 July 2010. 37 Lead in the plating layer of high voltage diodes on the basis of a zinc borate glass body. 38 Cadmium and cadmium oxide in thick film pastes used on aluminium bonded beryllium oxide.
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