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Test Report issued under the responsibility of:

TEST REPORT

IEC 6x xxx

Title of the IEC Standard

Report Reference No......................:

Date of issue....................................:

Total number of pages.......................

CB Testing Laboratory...........:

Address.....................................:

Applicants na!e............................:

Address............................................:

Test specification:

Standard...........................................: IEC 6x xxx - x : YEAR xxx Edition!

Test pro"edure..................................: C# $ CCA

%on-standard test met&od''''..: %$A

Test Report "or! No......................: IEC6xxxx(xY

Test Report )orms! *riginator.........: %ame of *riginator

+aster TR)......................................: Dated '

Copyri#ht $ %&&' IEC Syste! for Confor!ity Testin# and Certification of Electrical E(uip!ent)IECEE*+ ,ene-a+ S.it/erland0 All ri#hts reser-ed0

T&is publi"ation ma, be reprodu"ed in &ole or in part for non-"ommer"ial purposes as long as t&e IECEE is a"noledged as"op,rig&t oner and sour"e of t&e material. IECEE taes no responsibili t, for and ill not assume liabilit, for damages resulting from t&ereader/s interpretation of t&e reprodu"ed material due to its pla"ement and "ontext.

If t&is Test Report )orm is used b, non-IECEE members0 t&e IECEE$IEC logo and t&e referen"e to t&e C#

S"&eme pro"edure s&all be remo1ed.This report is not -alid as a C1 Test Report unless si#ned by an appro-ed C1 Testin# 2aboratory andappended to a C1 Test Certificate issued by an NC1 in accordance .ith IECEE &%0

Test ite! description000000000000000000000:

Trade +ar.......................................:

+anufa"turer....................................:

+odel$T,pe referen"e.......................:

Ratings.............................................:

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Testing procedure and testing location:

C1 Testin# 2aboratory:

Testing lo"ation$ address. :

Associated C1 Test 2aboratory:

Testing lo"ation$ address. :

Tested b, name 5 signature!..... .:

Appro1ed b, 5 signature!....... .... :

Testing pro"edure: T+2

Tested b, name 5 signature!..... .:

Appro1ed b, 5 signature!............:Testing lo"ation$ address. :

Testing pro"edure: +T

Tested b, name 5 signature!..... .:

itnessed b, 5 signature!...........:

Appro1ed b, 5 signature!....... .... :

Testing lo"ation$ address. :

Testing pro"edure: S+T

Tested b, name 5 signature!..... .:

Appro1ed b, 5 signature!........ .... :

Super1ised b, 5 signature!.........:

Testing lo"ation$ address. :

Testing pro"edure: R+T

Tested b, name 5 signature!..... .:

Appro1ed b, 5 signature!........ .... :

Super1ised b, 5 signature!.........:

Testing lo"ation$ address. :

TR) %o. IEC6x xxx(x,

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2age 7 of 43 Report %o.

Su!!ary of testin#:

Tests perfor!ed )na!e of test and test clause*: Testin# location:

Su!!ary of co!pliance .ith National 3ifferences:

Copy of !ar4in# plate

TR) %o. IEC6x xxx(x,

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Test ite! particulars................................................:

Classifi"ation of installation and use...........................:

Suppl, Conne"tion....................................................:

..................................................................................:

..................................................................................:

Possible test case -erdicts:

- test "ase does not appl, to t&e test ob8e"t................: %$A

- test ob8e"t does meet t&e re9uirement...................... : 2 2ass!

- test ob8e"t does not meet t&e re9uirement................: ) )ail!

Testin#......................................................................:

Date of re"eipt of test item.......................................... :

Date s! of performan"e of tests................................. :

,eneral re!ar4s:

T&e test results presented in t&is report relate onl, to t&e ob8e"t tested.T&is report s&all not be reprodu"ed0 ex"ept in full0 it&out t&e ritten appro1al of t&e Issuing testing laborator,.see En"losure ;! refers to additional information appended to t&e report.see appended table! refers to a table appended to t&e report.

T&roug&out t&is report a "omma point! is used as t&e de"imal separator.

General product information:

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2age < of 43 Report %o.

IEC 6xxxx

Clause Re9uirement 5 Test Result - Remar =erdi"t

.............................................................................:

.............................................................................:

.............................................................................:

.............................................................................:

.............................................................................:

.............................................................................:

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2age 6 of 43 Report %o.

IEC 6xxxx

Clause Re9uirement 5 Test Result - Remar =erdi"t

TA12E:

.............................................................................:

.............................................................................:

supplementar, information:

TA12E:

Comments

supplementar, information:

TA12E:

.............................................................................:

.............................................................................:

.............................................................................:

.............................................................................:

supplementar, information:

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2age > of 43 Report %o.

IEC 6xxxx

Clause Re9uirement 5 Test Result - Remar =erdi"t

TA12E:

result "ode

supplementar, information:

TA12E:

.............................................................................:

.............................................................................:

Supplementar, information:

TA12E: 5eatin# Test

Test 1oltage =!.....................................................:

Ambient oC!.........................................................:

T&ermo"ouple ?o"ations max. temperature measured0oC!

max. temperature limit0oC!

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2age @ of 43 Report %o.

IEC 6xxxx

Clause Re9uirement 5 Test Result - Remar =erdi"t

TA12E:

supplementar, information:

TA12E: dielectric stren#th

test 1oltage applied beteen: test potential applied =! breadon $ flas&o1er Yes$%o!

supplementar, information:

TA12E: i!pact resistance

impa"ts per surfa"e surfa"e tested impa"t energ, %m ! "omments

supplementar, information:

TA12E: electrical data )in nor!al conditions*

fuse ; I rated A! =! 2 ! I mA! I fuse mA! "ondition$status

supplementar, information:

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2age B of 43 Report %o.

IEC 6xxxx

Clause Re9uirement 5 Test Result - Remar =erdi"t

TA12E: clearance and creepa#e distance !easure!ents

"learan"e "l and "reepagedistan"e d"r at$of:

p=!

r.m.s. =! re9uired "lmm!

"l mm! re9uired d"rmm!

d"rmm!

supple!entary infor!ation:

TA12E: distance throu#h insulation !easure!ents

distan"e t&roug& insulation di at$of: r.m.s.=!

test 1oltage =! re9uired dimm!

dimm!

supplementar, information:

TA12E: ball pressure test of ther!oplastics

alloed impression diameter mm! .......................:

part test temperature C! impression diameter mm!

supplementar, information:

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2age 4 of 43 Report %o.

IEC 6xxxx

Clause Re9uirement 5 Test Result - Remar =erdi"t

TA12E: threaded part tor(ue test

t&readed part identifi"ation diameter of t&read mm! "olumn number I0 II0 or III!

applied tor9ue %m !

supplementar, information:

TA12E: o-er-olta#e and under-olta#e test

test operating"ondition

rated 1oltage=!

test 1oltage=!

temperatureoC!

"omments

supplementar, information:

National 3ifferences for )country na!e*

.............................................................................:

.............................................................................:

.............................................................................:

.............................................................................:

.............................................................................:

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2age 44 of 43 Report %o.

IEC 6xxxx

Clause Re9uirement 5 Test Result - Remar =erdi"t

.............................................................................:

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2age 43 of 43 Report %o.

2ist of test e(uip!ent used:)Note: This is an exa!ple of the re(uired attach!ent0 Other for!s .ith a different layout butcontainin# si!ilar infor!ation are also acceptable0*

Clause 7easure!ent 8testin# Testin# 8 !easurin# e(uip!ent 8!aterial used Ran#e used Calibration date