SUPPLIER RESTRICTED SUBSTANCE INFORMATION REPORTING FORM FOR (ATTACHMENT 1) NON-PRODUCTION DIMENSIONAL MATERIALS/PACKAGING MATERIALS/OFFICE MATERIALS, WSS-M99P9999-A1 Supplier Name______________________________ Global Supplier Data Base (GSDB) Code: ________________________ Supplier Contact: _______________________________ Supplier Phone: ________________ Ext: ___________________ Supplier FAX Number: ______________________ Supplier Email: _____________________________ Supplier Part Number: ___________________________ Supplier Part Description: ___________________ Ford Motor Company Engineering Contact: ________________________________ Phone Number: ____________________________ INSTRUCTIONS: The above item (by part number) contains the following substance(s) listed in the current version of the Ford Engineering Material Standard. Ford Motor Company WSS-M99P9999-A1 policy requires that suppliers disclose listed substance information related to the product supplied. Products, for which full disclosure of ingredients has been supplied to Toxicology according to Section 3.0 of the Standard, do not require additional reporting. Suppliers of facility equipment, machinery, and tooling (e g., conveyers, presses etc.), packaging materials, office materials and any sub-components contained therein, must utilize this form to submit information listed below including: 1) the name of the Production Line Equipment TOOLING AFFECTED that the sub-component part services, 2) if the part comes into direct contact with EMPLOYEE as a matter of routine use, 3) if the part contacts any material/part integral to the vehicle or other equipment that does so (i.e., affects MARKETS) and 4) if the part is a MAINTENANCE part that is periodically replaced and disposed. Suppliers of Facility equipment, or assembly aides whose main component contains no "sub-components", also utilize this form. PLEASE COMPLETE AND RETURN THIS FORM VIA FAX OR EMAIL TO NORTH AMERICAN GLOBAL MATERIALS & STANDARDS ENGINEERING : FAX 1-313-322-1614 or email RSMSstat@ford.com . The electronic version of this form is accessible at https://us.library.covisint.com/PublicDocViewer?nodeID=2179 REQUEST FOR ACKNOWLEDGEMENT: The above item (by part number) contains the following substance(s) listed in WSS-M99P9999-A1. Ford Motor Company will acknowledge receipt of this report I CERTIFY THAT THE ITEM(S) IDENTIFIED ON THIS FORM COMPLY WITH WSS-M99P9999-A1 Form completed by: ___________________________ Department: ___________________________ Date: ____________________ Equipment / Sub-Component Information Check all Tooling Supplier affected M E A M M I Tooling Affected Detailed Supplier P A N Material Listed substance by CAS Listed Production Line Supplier Part/ Part Material Primary Purpose L R T Name Material No. AND chemical name Substance Equipment Part/Spec Product Weight Weight or Use of Listed O K E 2 Std No. 3 in Material/Part Weight Y E N Name(s) / Numbers 1 Name (kg) (kg) Substance (kg) E T E Model No.(s) E S N S C E Ford Motor Company Acknowledgment: ________________________________________ Date: ______________________ (1) Supplier Part/Specification number used by Ford for procurement. (2) Report the weight (in kilograms) of the part supplied containing the listed substance. (3) Report the weight (in kilograms) of the material containing the listed substance. Submit additional signed copies of this form as necessary for additional Equipment/Tooling Suppliers
"Supplier Data Base"