Printed: January 9, 2011
Information Request – NSF Green Chemistry – Product Information
NSF International (NSF) is an independent, not-for-profit organization of scientists, engineers, technicians, educators, and analysts.
NSF currently provides testing, certification, and audit services for more than 130,000 products in 82 countries worldwide. It is a
trusted neutral non-governmental agency, serving government, industry, and consumers in achieving solutions to problems relating to
public health and the environment since 1944. The mission of NSF is to provide clients and the general public with objective, high
quality, timely, third-party certification services. Services include development of consensus standards, voluntary product testing and
certification with policies and practices which protect the integrity of registered Marks, education and training, and research and
demonstration, all relating to public health and the environmental sciences.
NSF Green Chemistry Program
NSF’s Green Chemistry Program performs reviews of product formulations and individual ingredients for conformity with environmental standards and recognition programs including:
; The U.S. Environmental Protection Agency, Design For the Environment (EPA - DfE) Formulator Program ; The GreenBlue Institute, for listing on the CleanGredients? website
; Green Seal environmental standards
; Environmental Choice standards
How does the process work?
; Submittal of the information requested on this form will initiate the process to obtain a time and cost estimate for NSF review
; NSF will review the information for completeness and provide the written cost estimate and corresponding contract. ; Upon receipt of a signed contract, and a 50% deposit, NSF will initiate the review process. NSF will request the following
information as needed to complete the reviews:
; Test data and other product information to confirm the formulation complies with the criteria of the respective
standard or recognition program (e.g. product performance test data, biodegradation studies for each ingredient, acute
aquatic toxicity data, human health toxicity data, etc.)
; Proprietary ingredient disclosure from your ingredient suppliers – NSF will provide forms that can be forwarded to
your suppliers. The forms will explain the nature of the request, and provide an opportunity to submit the information
directly and confidentially to NSF.
; An MSDS for each product and each ingredient
Only NSF authorized personnel are permitted accesses to the information provided on this form. The security of this form and the
information it contains is maintained through our confidential business information procedures and will not be revealed or provided to
unauthorized employees within the applicant’s company, ingredient suppliers, or other parties without your company’s prior written consent. See Section 4 of this form for EPA review for DfE recognition and CleanGredients? reviews.
AESOP 8284; ISSUE 3; STATUS-PUBLISHED; EFFECTIVE 15 AUG 2009 This document is the property of NSF International. Page 1 of 5
Printed: January 9, 2011
Information Request – NSF Green Chemistry NSF USE ONLY Product Information
Corporate #: _________________________
Project #: ___________________________
The information requested on this form is critical to the review of your product.
Please complete this form completely prior to submission. Please call 651-493-4247 for assistance.
1. Company information:
Company name Company contact
Address Telephone number ( )
FAX number ( )
2. Review type:
Please check the type of review you are seeking:
EPA DfE Recognition
Please attach: Product performance data
In order to list on CleanGredients? you must be a current supplier subscriber on www.cleangredients.org
Please attach: Biodegradability data
Aquatic toxicity data
Human health & safety data
Other (explain) ________________________
Please check additional testing you are seeking:
Product performance testing. EPA’s DfE Program requires product performance testing in order to recognize safer products.
Market leading product you would like NSF to evaluate your product against:
Compostability testing. EPA’s DfE Program requires compostability testing on all disposable wipe products.
Biodegradation testing. NSF offers biodegradation testing to support CleanGredients? reviews.
AESOP 8284; ISSUE 3; STATUS-PUBLISHED; EFFECTIVE 15 AUG 2009 This document is the property of NSF International. Page 2 of 5
Printed: January 9, 2011
3. Product Information: (please submit one page per formulation, use additional sheets as needed)
Product trade name: Type of product (all purpose cleaner, glass cleaner, surfactant, etc.)
pH of product (at point of sale): Production volume (lbs/yr)
Check if: Consumer Product / Industrial/Institutional Product
Check if: Product is an aerosol / Product is an EPA registered pesticide
Check if product is sold as: Ready-to-Use Formulation / A concentrate , if a concentrate what is the dilution ratio?
Type of material used in packaging (cardboard, HDPE, PETE, etc.) Percent recycled content in packaging %
4. Product Formulation: (for sample form and instructions, please see the last page of this form)
Ingredient Class Other supporting Check if (Surfactant, Fragrance, Supplier(s) (Include information: Number MSDS is % Chemical Name solvent, builder, chelator, Trade Name Alternate Suppliers) of ethoxylates, attached CAS No. Composition  pH adjustor…etc)  1 Supplier per line average chain length,      polymer MW, etc. 
Omission of information may significantly delay the completion of the review process.
ALL INFORMATION CONTAINED ON THIS PAGE IS CONFIDENTIALAESOP 8284; ISSUE 3; STATUS-PUBLISHED; EFFECTIVE 15 AUG 2009 This document is the property of NSF International. Page 3 of 5
Printed: January 9, 2011
4. Certification statement: (check one)
DfE and CleanGredients? applicants:
I hereby certify that, to the best of my knowledge, the information provided to NSF is accurate and complete. I understand that the information submitted may be used as a basis for reviewing/accepting other products which contain this material and/or the ingredients herein. I also understand and agree that the information I have provided on this form was requested for NSF’s Green Chemistry program, and that after review, this information and the review will be submitted to the EPA’s Design for the Environment Program.
All other review-type applicants:
I hereby certify that, to the best of my knowledge, the information provided to NSF is accurate and complete. I understand that the information submitted may be used as a basis for reviewing/accepting other products which contain this material and/or the ingredients herein.
For forms submitted electronically, check this box to indicate agreement to the applicable Certification Statement above (required).
Typed or printed name
5. Return instructions:
To send by e-mail, completely fill out the form, and type your name and contact information in Section 4. Check the box indicating your agreement with the certification statement. Send your e-mail with attachments to
To send by fax, completely fill out and sign the form, then fax to 734-827-6197. This fax number goes to a secure
computer for Amy McDade, Green Chemistry Project Manager for NSF International.
To send by U.S. mail or courier, insert completed form in an envelope marked "Confidential Business Information," seal in an outer envelope, and return to:
789 Dixboro Road
Ann Arbor, MI. 48105
AESOP 8284; ISSUE 3; STATUS-PUBLISHED; EFFECTIVE 15 AUG 2009 This document is the property of NSF International. Page 4 of 5
Printed: January 9, 2011
Formulation information: What should I enter in each column?
 The CAS number (Chemical Abstracts Service registry number) is a systematic numbering convention that uniquely
identifies each chemical. You may be able to find this information on the MSDS for the ingredient. If the ingredient is
a mixture of several chemicals, enter the word “mixture.” There are multiple resources available on the web and
elsewhere for finding specific CAS numbers (e.g., http://chem.sis.nlm.nih.gov/chemidplus/cmplxqry.html). All CAS
numbers are up to nine digits, which are separated into three groups by hyphens. The first part of the number, starting
from the left, has up to six digits; the second part after the first hyphen has two digits. Finally, the third part of the CAS
number following the last hyphen is single digit. For example, a CAS number may look 123456-12-1. If it is not in this
format, it is not a valid CAS number. If you cannot determine a CAS number for an ingredient, leave this area blank.
 The chemical name for each component can be found on the MSDS.
 The ingredient class can refer to: surfactants, solvents, chelators, fragrances, preservatives/biocide, builders, hydrotropes,
sequestrants, dispersants, sanitizer, dyes/colorants, enzyme/microorganisms, fragrances, and other.
 The trade name is the unique name or identification number of the ingredient as you buy it from your supplier. This
information can be obtained from your purchasing department.
 The supplier is the company from whom you buy this ingredient. If you know that your supplier is a distributor, and
you know the name of the company that manufactures the ingredient, please enter both company names here. Write (D)
after the distributor’s name, and (M) after the manufacturer’s name. For each ingredient that you buy from more than
one supplier, please enter each chemical name, trade name, supplier, and % on a separate line.
 A single surfactant CAS number may represent a wide range of carbon chain length and/or number of ethoxylates.
Polymers may have varying molecular weights and residual monomers. Detailed information on the specific chemical
you are using will help NSF perform an accurate review of your ingredient.
 The percentage in the ingredient must be completed for each component. The total of all components must always equal
 NSF requests ingredient MSDS’s wherever available, they help identify useful information regarding composition,
physical and chemical properties, indicate types of test data that may be available, etc.
An example of a completed formulation is shown below:
Ingredient Other supporting Class information: Supplier(s) (Include Check if  Number of % Chemical Name Trade Name Alternate Suppliers) MSDS is CAS No. ethoxylates, Composition   1 Supplier per line attached  average chain    length…etc. 
68131-39-5 Alcohols, Surfactant Surfactant 1 Company A C12-15, 14.25 Ethoxylated Average 7EO
67762-38-3 Methyl soyate Solvent Solvent 1 Company B C12-18 35.75
Proprietary Proprietary Fragrance Rain Drops # Company C N/A 0.003 302710
Proprietary Proprietary Dispersant Dispersant 1 Company D MW >27,000, 1.18
acrylic <2ppm styrene
7732-18-5 Water Solvent N/A Company (or N/A balance municipality) E
AESOP 8284; ISSUE 3; STATUS-PUBLISHED; EFFECTIVE 15 AUG 2009 This document is the property of NSF International. Page 5 of 5