EHS 1001 Compliance Forms

Xerox Third-Party Confidential
EHS-1001 Instructions
Form Version 8.3
NOTE: DO NOT DELETE THIS CONTROL WORKSHEET FROM THE FILE,

IT IS NECESSARY FOR XEROX PROCESSING
General Instructions for Completing the EHS-1001 Declaration Form

*** You will need to read the Xerox Supplier Requirements before completing this form.
The "Supplier Requirements: EHS&S 1001: Chemical Bans/Restrictions and Part Marking" and
other compliance documents contain more comprehensive details regarding the requirements
being agreed to on this form.
A copy of these Supplier Requirement documents can be found at Xerox URL:
http://www.xerox.com/about-xerox/environment/clean-manufacturing/chemicals/enus.html
File Format
> To facilitate processing of this document, please provide completed EHS1001 declarations in
both the original Excel format and a signed copy in PDF format. (See Supplier Signature section
below.)
Tab Layout
> Do not modify the cell layout of any tab. This includes inserting rows or columns or merging cells. The
software that processes these documents requires that the data be located in specific cells.
Data Input
> All data fields must be completed unless specified as Optional.
> If you use Copy&Paste to enter data into the spreadsheets, make sure you use the option "Paste
Special"->"Values". The tabs for EHS-1001A,B,&C have specific rules for allowed values. Using the
normal "Paste" option will overwrite these rules and potentially cause your submitted document to be
rejected by the Xerox compliance system.
> Do not add the new-line character to cells. All data in a single cell must be in one continuous line. It is
acceptable for the text to "wrap", like this instruction line does, as long as it does not have line breaks in
it. Here is an example of what would fail:
This cell
has line breaks
in it.
> Each EHS1001 form submission should be as comprehensive as possible. That is, suppliers should not
submit only one tab on the form, if data about the other tabs is also known. For example, if an EHS1001
form is submitted by the supplier in January for Xerox part number 205E00001, with only the EHS-1001A
and EHS-1001C tabs completed, and then in February the supplier is ready to submit answers to the
questions on EHS-1001B, then the supplier should submit the new EHS-1001 form with all three tabs
completed for part number 205E00001. Do not just complete the EHS-1001B tab. The goal is to have all
relevant information for that part number, from that supplier, be on the same EHS-1001 document.
> Similar to above, any update or correction to information being declared about a part number on an EHS-
1001 form should always be comprehensive for each part. For example, if an EHS-1001 form was sent in
January declaring usage of Antimony in part number 205E00001 and then in February, the supplier
discovers and wants to also declare Arsenic usage for the same part, then the newly submitted EHS-
1001 form should declare both the Antimony and Arsenic usage, not just the additional substance. That
is, all data about the part should be included with each submission because it replaces any previously
submitted data for that part.
Assembly Suppliers
EHS 1001 Xerox EHS Supplier Requirements: Control Sheet v. 8.3, effective April 17, 2017 Page 1 of 18
> Assembly suppliers must list all Xerox assembly part numbers being certified as RoHS compliant and the
Xerox component part numbers. If the Assembly contains components that do not have Xerox Part
Numbers, than the supplier should roll-up the compliance declaration information for those parts under
the Xerox Part Number they go into. (See instructions for Supplier Internal Breakdowns.) We expect that
an assembly supplier will have certificates of compliance, from their component suppliers, and be able to
provide those component certification documents (including suitable letters/analysis/information)
immediately upon request by Xerox.
Supplier Internal Breakdowns or Alternate Parts

> The EHS-1001 form is intended for declarations of compliance or substance usage at the Xerox part
number level. Any declarations of compliance or substance usage should always be rolled-up to a Xerox
Part Number and not be declared only against supplier internal break down part numbers.
> If a Supplier is declaring an assembly made of other Xerox Part Numbers, then each separate Xerox Part
Number should be included on its own row.
> A single supplier can only declare a Xerox Part Number once. Any additional declaration for the same
Xerox Part number will REPLACE the previous declaration.
> If there are alternative supplier parts for the same Xerox Part Number, then declare the worst possible
case of compliance and substance usage.
> See the instructions below for EHS-1001A, EHS-1001B & EHS-1001C for more details about how to
handle alternate supplier parts or the inclusion of supplier breakdowns.
Instructions for common fields.

Date (MM/DD/YY)
> Enter the date the EHS1001 form was completed.
Supplier Information
> Please complete the supplier information section at the top of each tab on which you provide part
number information. Include the contact name of the person from your company that is responsible for
submitting this document to Xerox and the address information for your company.
Supplier Email Address
> Please provide the email address of the person responsible for submitting this compliance document to
Xerox. If you are submitting this document electronically, then this email address will be used to inform
you of any errors found on the document.
Supplier Signature
> * Submitted EHS1001 forms must have an actual hand written signature, on the signature line, by an
authorized representative of the Supplier. The signed hard copy forms should be faxed or emailed to
your Xerox contact (along with a copy of the completed Excel format document). A "scanned signature
picture" pasted onto the signature line of the forms or a typed name using a "script font" is not
acceptable.
Xerox Part Number [Required]

> List the Xerox Part Number being declared. This field is required on all tabs. If the Xerox Part Number
field is left blank, then no data on the rest of that row will be digitally recorded.
> A supplier can only declare a Xerox Part Number once. Any additional declaration for the same Xerox
Part number will REPLACE the previous declaration for that Xerox Part Number. The two exceptions to
this rule are if the supplier is declaring multiple RoHS Exemptions on EHS-1001A or multiple SVHC
usage on EHS-1001C. See the instructions for those tabs for more details.
> Only list a single Xerox Part number on each row. Do not include revision information or any additional
text that is not part of the Part Number. Most Xerox part numbers are in one of the following two formats.
NNNANNNNN : Where N is a digit and A is a letter. Example: 205E12345
NNN-NNNN-NN : Where N is a digit. Example: 006-1234-00. This is also often displayed without the
hyphens or leading zeros. Example 6123400.
> Here are some examples of things to avoid for Xerox Part Number 205E12345 :
205E12345 revA
205E12345A
XRX205E12345
Supplier Identifier [Optional]

> Please list the part number as it is identified within your company. If more than one supplier identifier is
used for the same Xerox Part Number, then list all the identifiers, separated by commas, and also read
the instructions on this page concerning supplier breakdowns and alternative parts.
Part Description (Form EHS-1001A & EHS-1001C) [Optional]
> Provide a description of the part. If the part contains a battery, please also include the battery identifier in
this description. (Please avoid using any new-line breaks in the description. See instruction in "Data Input
section.)
Form EHS-1001A Banned Substances (completion required)

EHS-1001A includes compliance requirements for ODS, RoHS, EU Battery Directive, ISO standard 11469, and
other prohibited substances.
*** Refer to the "EHS-1001 Xerox Environment, Health and Safety Supplier Requirements:
Chemical Bans/Restrictions and Part Marking" document for more details regarding the following
requirements.
Xerox Compliance Requirements
> Xerox will not accept parts that have a compliance response of "No" for any of the questions below that
are proceeded by any asterisk. (*)
* 2.1 Regulatory Compliance (Column D) [Optional]
> This signifies your company's intent to comply with Xerox Environment, Health and Safety regulations.
Use the drop-down menu to select "Yes" or "No"
* 2.2 Ozone Depleting Substances (Column E) [Required]
> Use the drop-down menu to select "Yes" or "No" to indicate compliance with ODS requirements.
* 2.3 RoHS (Column F) [Required]
> Use the drop-down menu to select "Yes", "Yes with Exemption", "No", or "Not Applicable" to indicate this
part's compliance status with regards to the RoHS Directive.
"Yes with Exemption" means that the part is compliant, but it uses one of the exemptions listed in table
A3 of the Xerox EHS Supplier Requirements document. "Not Applicable" is used for parts that are not
covered under the RoHS Directive.
(Column G) [Ignore]
> Ignore this column.
2.3 RoHS Exemption (Column H) [Required]

> Exemptions apply to specific applications of specific materials and do not apply to specific Suppliers.
Exemptions are formally approved by the EU and are included in the RoHS Directive. For the most part,
exemptions are considered temporary and are initially granted due to general acceptance that technically
feasible substitutes are not available. Once an alternative is available, the exemption will be formally
discontinued by the EU, and a compliance deadline will be specified. By this date, a part will have to
become compliant and be certified by the supplier.
> If "Yes with Exemption" was selected for RoHS compliance, then specify the exemption being used by
selecting the exemption number from the drop-down menu.
If the part number uses more than one exemption, then create a completely duplicate row for the part
number with the same answer for all other columns, but select the additional exemption number.
Example:
2.3 Percentage by weight (Column I) [Optional]

> (This is optional and can be skipped if not known.) If this part/item is using a RoHS Exemption, then
specify the exemption material's percentage of weight for the part/item.
* 2.3 Other Prohibited Substance (Column J) [Required]
> Use the drop-down menu to select "Yes" or "No" to indicate this part's compliance with the" Other
Prohibited Substances" requirement listed in table A2 of the Xerox EHS Supplier Requirements
document.
2.3 Batteries [Required]

> If the specified part contains a battery, list the weight of the battery in grams. Also add the battery
identifier number to the description in column "C".
* 2.4 Parts Marking [Required]
> Use the drop-down menu to select "Yes", "No", or "Not Applicable" to indicate this part's compliance
status with regards to the Parts Marking requirement described in section 2.4 of the Xerox EHS Supplier
Requirements document.
EHS-1001A Example for Supplier Internal Breakdowns or Alternate Parts

> Per the General Instructions above, the EHS1001 form is meant to declare compliance and substance
usage at the Xerox Part Number level, not supplier internal breakdowns. However, if the supplier wishes
to list an assembly breakdown or alternate parts they can but they must roll-up any usage declaration
to the single row with the Xerox Part Number.
Example of Supplier Assembly Breakdown
> In this example the Xerox Part Number, 205K00001, is being reported and the three supplier
components have been included.
> This is what should NOT be done:
> The correct way to report the Xerox Part Number is below. The data from the three components has
been rolled-up into the single line for the Xerox Part Number. In this example, the Supplier's internal
breakdown has still been included, but the Xerox Part Number column has been left blank. These extra
rows will not be digitally stored, but would be available for reference on the actual form. Also note that
including a Supplier's internal breakdown, which consists of only Supplier Part Numbers, is not
necessary.
Example of Supplier Alternate Parts for same Xerox Part Number

> Per the General Instructions above, a single supplier can only have one EHS1001 declaration per Xerox
Part Number. Any additional declaration for the same Xerox Part number, from the same supplier, will
REPLACE the previous declaration. If the supplier has multiple or alternate parts for the same Xerox Part
Number, they must roll-up any usage declaration to the single row with the Xerox Part Number using the
worse possible response for each question.
> This is an example of what should NOT be done:
> The above should instead be combined into one entry, as shown below:
Form EHS-1001B Reportable Substance (completion required)

Form-B is for the declaration of substances specified in Section A.3.ii in Table B1 of EHS-1001. This
compositional detail is specified in the Joint Industry Guide Material Composition Declaration for
Electrotechnical Products. It is necessary to satisfy regulatory requirements and to provide information to
customers, recyclers and waste contractors.
requirements.
Location of Reportable Substance [Optional]
> Describe the general location of any Reportable Substance usage. If multiple substances are declared,
all locations can be listed in the same location description box.
Antimony (Sb) Compound [Required]
> Use the drop-down menu to select "Yes" or "None" to indicate usage of this substance.
Arsenic (As) compound [Required]
Beryllium (Be) compound [Required]
Carbon Nanotubes [Required]
Nickel (Ni) compound [Required]
Perchlorates [Required]
Selenium (Se) compound [Required]
Brominated Flame Retardant [Required]
> Use the drop-down menu to select "Yes" or "None" to indicate usage of this substance. Please note that
certain types of usage are restricted.
Chlorinated Flame Retardant [Required]
PVC [Required]
Di-isodecyl phthalate (DIDP)
Diisononyl phthalate (DINP)
EHS-1001B Example for Supplier Internal Breakdowns or Alternate Parts

to list an assembly breakdown or alternate parts they can, but they must roll-up any usage declaration
been rolled-up into the single line for the Xerox Part Number. Notice how the "Yes" values from the
three original rows have been combined into the single row responses. In this example, the Supplier's
internal breakdown has still been included, but the Xerox Part Number column has been left blank.
These extra rows will not be digitally stored, but would be available for reference on the actual form. Also
note that including a Supplier's internal breakdown, which consists of only Supplier Part Numbers, is not
necessary.

> The above should be combined into one entry, as shown below: Notice how the "Yes" values from the
two original rows have been combined into the single row responses.
Form EHS-1001C REACH (completion required)

Form-C is for declaration of ‘Substances of Very High Concern ‘(or SVHCs). REACH, the European Union
regulation concerning the Registration, Evaluation, Authorization and restriction of Chemicals (No. 1907/2006)
entered into force on the 1st of June 2007. REACH requires that the presence of a specific list of chemicals,
known as “SVHCs”, are disclosed. This identification requirement applies to virtually all items in commerce in
any form, including chemical preparations and articles. Following a European Court of Justice Ruling in
September 2015 the requirement applies at component level for all articles/parts. The presence of SVHCs at
concentrations greater than 0.1% by weight is to be communicated throughout the supply chain, and to
consumers upon request. Additionally, the use of an SVHC in a given application, including incorporation into
articles/parts, may, ultimately, need to be reported to the European Chemicals Agency (ECHA) and may be
subject to future authorizations for use. Complete this form for any materials, parts, or products supplied to
Xerox.
requirements.
Weight of Part (grams) [Required]
> Indicate the weight of the part/item in grams. This value is only required if any SVHC CAS# value,
other than "NONE", is declared.
SVHC CAS # [Required]
> Use the drop-down menu to indicate if any SVHC is used in this part. If no SVHC is used, then select
"NONE".
> If the part uses more than one SVHC, then create a completely duplicate row for the part number with
the same answer for all other columns, but select the additional SVHC CAS# and the Weight of the
SVHC. (Similar to the method described above for multiple RoHS Exemptions on EHS-1001A.)
Weight of SVHC (grams) [Required]
> Indicate the weight of the SVHC in grams. This value is only required if any SVHC CAS# value, other
than "NONE", is declared.
SVHC Description [Do Not Edit]
> Do not edit this value. This text will automatically be populated based on the SVHC CAS# selected in
column E. The value is not record and is only intended to help describe the selected SVHC.
EHS-1001C Example for Supplier Internal Breakdowns or Alternate Parts

to list an assembly breakdown or alternate parts they can, but they must roll-up any usage declaration
been rolled-up into the single line for the Xerox Part Number. In this example, the Supplier's internal
breakdown has still been included, but the Xerox Part Number column has been left blank. These extra
rows will not be digitally stored, but would be available for reference on the actual form. Also note that
including a Supplier's internal breakdown, which consists of only Supplier Part Numbers, is not
necessary.

> The above should be combined into one entry, as shown below: Notice how the SVHC for one of the
alternates is included in the combined entry.
NOTE: Do not make any changes to this form template; add or delete rows or columns, create splits or merges, add or remove any sheets etc.
Xerox Form EHS-1001 A Supplier Certification of Compliance, version 8.3

Date (MM/DD/YY) Supplier ID (Optional. Leave blank unless value provided by Xerox.)
Supplier Name Supplier Site Code (Optional. Leave blank unless value provided by Xerox.)
Contact Person
Title The information provided will be used solely for the purpose of
Address supporting compliance with the EU RoHS Directive and other chemical
City, State or Country, Postal Code restrictions. Xerox will not transfer forward any business contact information
to third parties except as permitted by applicable privacy legislation
Phone and Fax Numbers
and/or to demonstrate compliance with RoHS or other chemical restrictions.
E-mail Address
Xerox Product Description: (Optional)
For items supplied to Xerox, complete this table to indicate your current status in meeting the requirements of "EHS-1001 Xerox Environmental, Health and Safety Supplier Requirements: ODS, RoHS, other prohibited substances, reportable
substances and ISO standard 11469". Supplier hereby certifies that this information accurately represents the supplier's status in meeting these requirements. Supplier further certifies that the status indicated below will remain accurate at the
time of delivery of all identified items/parts to Xerox and all Supplier changes or replacements of such parts/items. Note: Xerox reserves the right to review supplier's test data as proof of compliance with these requirements.
Signature: Date:
Name / Title:
Please read the "Control Sheet" tab for instructions on completing each 2.1 Regulatory 2.2 Ozone Depleting
field and how to enter multiple values. Compliance Substances (ODS) 2.3 Chemical Substance Bans and Restrictions 2.4 Parts Marking
A.3.ii Batteries-If part

We comply with the A.3.i This item complies with the RoHS A.3.i This item contains a battery, enter the
requirement that prohibits requirements listed in Table A1 (inclusive of A.3.i If the item supplied contains exempted complies with the supplier/Xerox battery part
We are committed to use of ODS in the RoHS Phthalates) and Table A3. (If the item uses of RoHS materials per Table A3 in the Other Prohibited number in description This item complies with
compliance with all manufacture or uses a material exemption from Table A3 then EHS1001, select exemption number (column Substances (column C) and the weight the requirement to mark
applicable EH&S laws processing of items select "Yes with Exemption" and specify H) and state percent by weight for the requirement listed in of the battery in grams plastic parts per ISO
and regulations supplied to Xerox exemption number in column "H".) substance used in column I) Table A2; below. Standard 11469.
Xerox Part Number - part numbers
must be entered and match the way
they are on your PO. Do not drop Reply 'Yes', 'Yes with
off any zeros or dashes. Also, do Supplier Identifier - Exemption', 'No', or 'Not Select Exemption Number
Applicable' if this part is from drop-down menu or Percentage
not add any additional prefixes or supplier's part Description of Item outside the scope of leave blank if no RoHS by weight. Reply Yes, No or Not
suffixes. number. (Optional) (Optional) Reply: Yes or No Reply Yes or No RoHS. exemption is used. (Optional) Reply Yes or No Battery weight in grams Applicable
EHS 1001 Xerox EHS Supplier Requirements: Form-A Chemical Bans/Restrictions and Part Marking v. 8.3, effective April 17, 2017 Page 8 of 18
Xerox Form EHS-1001 B Supplier Use of "Reportable" Substances, version 8.3

Date (MM/DD/YY) Supplier ID (Optional. Leave blank unless value provided by Xerox.)
Supplier Name Supplier Site Code (Optional. Leave blank unless value provided by Xerox.)
Contact Person
Title The information provided will be used solely for the purpose of supporting compliance with waste
Address legislation/regulations. Xerox will not transfer forward any business contact information to third parties
City, State or Country, Postal Code except as permitted by applicable privacy legislation and/or to demonstrate and enable compliance with
waste legislation and regulations.
E-mail Address
For items supplied to Xerox, use this form to “report” substances considered for use in equipment, spare parts, or accessories. If there are none, select "none". Supplier hereby certifies that this information accurately represents the supplier's use
of "reportable" substances. Supplier further certifies that the information indicated below will remain accurate at the time of delivery of all identified items/parts to Xerox and all Supplier changes or replacements of such parts/items. Note: Xerox
reserves the right to review supplier's test data as proof of accuracy of this information.
Signature: Date:
Name / Title:
Please read the "Control Sheet" tab for instructions on completing each field and Halogenated Material - Brominated and Chlorinated flame retardants and PVC A.3.ii Reportable
how to enter multiple values. are already restricted from external plastic casings and enclosures - see Table Substances, Table B1.
A.3.ii Reportable Substances, Table B1 A2. PVC is also restricted from packaging. Please indicate if the part has any Additional substance usage.
Are any of the substances listed below used in the part, product or packaging you provide. Please answer "Yes" or "None". other usage of BFR, CFR or PVC by indicating "Yes" or "None". (Note: SCCP's, Please answer "Yes" or
It is not necessary to provide the concentration level of the substance. PBB's, PBDE's HBCDD are prohibited per Table A1 and A2) "None".

they are on your PO. Do not drop
off any zeros or dashes. Also, do Supplier Identifier - Location of Reportable
Di-isodecyl Diisononyl
not add any additional prefixes or suppliers part number. Substance, (e.g. motor, Antimony (Sb) Arsenic (As) Beryllium (Be) Carbon Nickel (Ni) Selenium (Se) Brominated Flame Chlorinated Flame phthalate phthalate
suffixes. (Optional) board, etc.) (Optional) Compound compound compound Nanotubes compound Perchlorates compound Retardant Retardant PVC (DIDP) (DINP)
EHS 1001 Xerox EHS Supplier Requirements: Form-B Reportable Substances v. 8.3, effective April 17, 2017 Page 9 of 18
Xerox Form EHS-1001 C Supplier Use of REACH Substances, version 8.3

Date (MM/DD/YY) Supplier ID (Optional)
Supplier Name Supplier Site Code (Optional)
Contact Person
Title The information provided will be used solely for the purpose of supporting compliance
Address with the EU REACH Directive and other waste legislation/regulations. Xerox will not
City, State or Country, Postal Code transfer forward any business contact information to third parties except as permitted
by applicable privacy legislation and/or to demonstrate and enable compliance with
REACH or other waste legislation and regulations.
E-mail Address
For items to component level supplied to Xerox, use this form to identify and quantify the presence of any substances that are included in the Candidate List of Substances of Very High Concern (SVHC) for authorization under the European Union’s
REACH Regulation. If there are none, select "none". Supplier hereby certifies that this information accurately represents the supplier's use of "reportable" substances and that any change following future additions to the Candidate List will be
communicated to Xerox. Supplier further certifies that the information indicated below will remain accurate at the time of delivery of all identified items/parts to Xerox and all Supplier changes or replacements of such parts/items. Note: Xerox
reserves the right to review supplier's test data as proof of accuracy of this information.
Signature: Date:
Name / Title:
Please read the "Control Sheet" tab for instructions on completing each field and how to enter multiple values.

they are on your PO. Do not drop SVHC CAS #
off any zeros or dashes. Also, do Supplier Identifier - SVHC Description
not add any additional prefixes or suppliers part number. Weight of Part (Only select items from pull Weight of SVHC
suffixes. (Optional) Part Description (Optional) (grams) down menu.) (grams) (This field will auto populate upon selection of CAS#.)
EHS 1001 Xerox EHS Supplier Requirements: Form-C REACH SVHC v. 8.3, effective April 17, 2017 Page 10 of 18


Do Not Edit the Contents of this Tab.
Form C - CAS # SVHC Description Notes
NONE No reportable REACH substance greater than 0.1% per EHS1001
Aluminosilicate RCF Aluminosilicate Refractory Ceramic Fibres
reaction mass of 2-ethylhexyl 10- reaction mass of 2-ethylhexyl 10-ethyl-4,4-dioctyl-7-oxo-8-oxa-3,5-dithia- New on Version 8.1
ethyl-4,4- 4-stannatetradecanoate and 2-ethylhexyl 10-ethyl-4-[[2-[(2-
ethylhexyl)oxy]-2-oxoethyl]thio]-4-octyl-7-oxo-8-oxa-3,5-dithia-4-
stannatetradecanoate (reaction mass of DOTE and MOTE)
Sodium perborate; perboric acid, Sodium perborate; perboric acid, sodium salt New on Version 8.1
sodium salt
Zirconia aluminosilicate RCF Zirconia Aluminosilicate Refractory Ceramic Fibres
10043-35-3 Boric acid
10099-74-8 Lead dinitrate New on Version 8.0
10108-64-2 Cadmium chloride New on Version 8.1
101-14-4 2,2'-dichloro-4,4'-methylenedianiline New on Version 8.0
10124-36-4 Cadmium sulphate New on Version 8.1
10124-43-3 Cobalt(II) sulphate New on Version 8.0
10141-05-6 Cobalt(II) dinitrate New on Version 8.0
101-61-1 N,N,N',N'-tetramethyl-4,4'-methylenedianiline (Michler’s base) New on Version 8.0
101-77-9 4,4′- Diaminodiphenylmethane
101-80-4 4,4'-oxydianiline and its salts New on Version 8.0
10588-01-9 Sodium dichromate
106-94-5 1-bromopropane New on Version 8.0
107-06-2 1,2-dichloroethane New on Version 8.0
109-86-4 2-Methoxyethanol New on Version 8.0
110-00-9 Furan New on Version 8.0
110-71-4 1,2-dimethoxyethane; ethylene glycol dimethyl ether (EGDME) New on Version 8.0
110-80-5 2-Ethoxyethanol New on Version 8.0
11103-86-9 Potassium hydroxyoctaoxodizincatedichromate New on Version 8.0
11113-50-1 Boric acid
111-15-9 2-Ethoxyethyl acetate New on Version 8.0
11120-22-2 Silicic acid, lead salt New on Version 8.0
111-96-6 Bis(2-methoxyethyl) ether New on Version 8.0
1120-71-4 1,3-propanesultone New on Version 8.2
112-49-2 1,2-bis(2-methoxyethoxy)ethane (TEGDME; triglyme) New on Version 8.0
115-96-8 tris(2-chloroethyl)phosphate
1163-19-5 Bis(pentabromophenyl) ether (DecaBDE) New on Version 8.0
117-81-7 Bis (2-ethyl(hexyl)phthalate) (DEHP)
117-82-8 Bis(2-methoxyethyl) phthalate New on Version 8.0
120-12-7 Anthracene
12036-76-9 Lead oxide sulfate New on Version 8.0
12060-00-3 Lead titanium trioxide New on Version 8.0
12065-90-6 Pentalead tetraoxide sulphate New on Version 8.0
120-71-8 6-methoxy-m-toluidine (p-cresidine) New on Version 8.0
121-14-2 2,4-Dinitrotoluene
12141-20-7 Trilead dioxide phosphonate New on Version 8.0
12179-04-3 Disodium tetraborate, anhydrous
12202-17-4 Tetralead trioxide sulphate New on Version 8.0
12267-73-1 Tetraboron disodium heptaoxide, hydrate
123-77-3 Diazene-1,2-dicarboxamide (C,C'-azodi(formamide)) New on Version 8.0
12578-12-0 Dioxobis(stearato)trilead New on Version 8.0
12626-81-2 Lead Titanium Zirconium Oxide New on Version 8.0
12656-85-8 Lead chromate molybdate sulphate red (C.I. Pigment Red 104)
127-19-5 N,N-dimethylacetamide New on Version 8.0
1303-28-2 Diarsenic pentaoxide
1303-86-2 Diboron trioxide New on Version 8.0
1306-19-0 Cadmium oxide New on Version 8.1
1306-23-6 Cadmium sulphide New on Version 8.1
131-18-0 Dipentyl phthalate (DPP) New on Version 8.1
1314-41-6 Lead tetroxide (orange lead) New on Version 8.0
13149-00-3 cis-cyclohexane-1,2-dicarboxylic anhydride, Hexahydro-2-benzofuran- New on Version 8.0
1,3-dione (cis-HHPA)
1317-36-8 Lead oxide (lead monoxide) New on Version 8.0
1319-46-6 Trilead bis(carbonate)dihydroxide (basic lead carbonate) New on Version 8.0
1327-53-3 Diarsenic trioxide
1333-82-0 Chromium trioxide New on Version 8.0
134237-50-6 Hexabromocyclododecane-Alpha (HBCDD)
134237-51-7 Hexabromocyclododecane-Beta (HBCDD)
134237-52-8 Hexabromocyclododecane-Gamma (HBCDD)
13424-46-9 Lead diazide, Lead azide New on Version 8.0
1344-37-2 Lead sulfochromate yellow (C.I. Pigment Yellow 34)
EHS 1001 Xerox EHS Supplier Requirements: Reach SVHC and RoHS Exemptions v. 8.3, effective April 17, 2017
13530-68-2 Acids generated from chromium trioxide and their oligomers. Group New on Version 8.0
containing: Chromic acid, Dichromic acid, Dichromic acid, Oligomers of
chromic acid and dichromic acid
13814-96-5 Lead bis(tetrafluoroborate) New on Version 8.0
140-66-9 4-(1,1,3,3-tetramethylbutyl)phenol New on Version 8.0
14166-21-3 trans-cyclohexane-1,2-dicarboxylic anhydride, Hexahydro-2-benzofuran- New on Version 8.0
1,3-dione (trans-HHPA)
143860-04-2 3-ethyl-2-methyl-2-(3-methylbutyl)-1,3-oxazolidine New on Version 8.0
15245-44-0 Lead styphnate New on Version 8.0
15571-58-1 2-ethylhexyl 10-ethyl-4,4-dioctyl-7-oxo-8-oxa-3,5-dithia-4- New on Version 8.1
stannatetradecanoate (DOTE)
15606-95-8 Triethyl arsenate
17570-76-2 Lead(II) bis(methanesulfonate) New on Version 8.0
1937-37-7 Disodium 4-amino-3-[[4'-[(2,4-diaminophenyl)azo][1,1'-biphenyl]-4- New on Version 8.1
yl]azo] -5-hydroxy-6-(phenylazo)naphthalene-2,7-disulphonate (C.I.
Direct Black 38)
19438-60-9 Hexahydro-4-methylphathalic anhydride (MHHPA) New on Version 8.0
2058-94-8 Henicosafluoroundecanoic acid New on Version 8.0
20837-86-9 Lead cyanamidate New on Version 8.0
21049-39-8 Sodium salts of perfluorononan-1-oic-acid New on Version 8.2
2451-62-9 TGIC (1,3,5-tris(oxiranylmethyl)-1,3,5-triazine-2,4,6(1H,3H,5H)-trione) New on Version 8.0
24613-89-6 Dichromium tris(chromate) New on Version 8.0

25155-23-1 Trixylyl phosphate New on Version 8.1
25214-70-4 Formaldehyde, oligomeric reaction products with aniline New on Version 8.0
25550-51-0 Hexahydromethylphathalic anhydride (MHHPA) New on Version 8.0
25637-99-4 Hexabromocyclododecane (HBCDD)
2580-56-5 [4-[[4-anilino-1-naphthyl][4-(dimethylamino)phenyl]methylene]cyclohexa- New on Version 8.0
2,5-dien-1-ylidene] dimethylammonium chloride (C.I. Basic Blue 26)
25973-55-1 2-(2H-benzotriazol-2-yl)-4,6-ditertpentylphenol (UV-328) New on Version 8.1

301-04-2 Lead di(acetate) New on Version 8.1
302-01-2 Hydrazine New on Version 8.0
307-55-1 Tricosafluorododecanoic acid New on Version 8.0
3108-42-7 Ammonium nonadecafluorodecanoate New on Version 8.3
31119-53-6 Cadmium sulphate New on Version 8.1
3194-55-6 Hexabromocyclododecane (HBCDD)
335-67-1 Pentadecafluorooctanoic acid (PFOA) New on Version 8.1
335-76-2 Nonadecafluorodecanoic acid (PFDA) New on Version 8.3
36437-37-3 2-(2H-benzotriazol-2-yl)-4-(tert-butyl)-6-(sec-butyl)phenol (UV-350) New on Version 8.2
3687-31-8 Trilead diarsenate New on Version 8.0
375-95-1 Perfluorononan-1-oic-acid New on Version 8.2
376-06-7 Heptacosafluorotetradecanoic acid New on Version 8.0
3825-26-1 Ammonium pentadecafluorooctanoate (APFO) New on Version 8.1
3830-45-3 Decanoic acid, nonadecafluoro-, sodium salt New on Version 8.3
3846-71-7 2-benzotriazol-2-yl-4,6-di-tert-butylphenol (UV-320) New on Version 8.1
3864-99-1 2,4-di-tert-butyl-6-(5-chlorobenzotriazol-2-yl)phenol (UV-327) New on Version 8.2
4-(1,1,3,3-tetramethylbutyl)phenol, 4-(1,1,3,3-tetramethylbutyl)phenol, ethoxylated - covering well-defined New on Version 8.0
ethoxylated substances and UVCB substances, polymers and homologues
4149-60-4 Ammonium salts of perfluorononan-1-oic-acid New on Version 8.2
49663-84-5 Pentazinc chromate octahydroxide New on Version 8.0

4-heptylphenol, branched and 4-heptylphenol, branched and linear substances with a linear and/or New on Version 8.3
linear substances branched alkyl chain with a carbon number of 7 covalently bound
predominantly in position 4 to phenol, covering also UVCB- and well-
defined substances which include any of the individual isomers or a
combination thereof
4-Nonylphenol, branched and 4-Nonylphenol, branched and linear - substances with a linear and/or New on Version 8.0
linear branched alkyl chain with a carbon number of 9 covalently bound in
position 4 to phenol, covering also UVCB- and well-defined substances
which include any of the individual isomers or a combination thereof
4-Nonylphenol, branched and 4-Nonylphenol, branched and linear, ethoxylated [substances with a New on Version 8.1
linear, ethoxylated linear and/or branched alkyl chain with a carbon number of 9 covalently
bound in position 4 to phenol, ethoxylated covering UVCB- and well-
defined substances, polymers and homologues, which include any of
the individual isomers and/or combinations thereof]
50-32-8 Benzo[def]chrysene (Benzo[a]pyrene) New on Version 8.3

513-79-1 Cobalt(II) carbonate New on Version 8.0
51404-69-4 Acetic acid, lead salt, basic New on Version 8.0
548-62-9 [4-[4,4'-bis(dimethylamino) benzhydrylidene]cyclohexa-2,5-dien-1- New on Version 8.0
ylidene]dimethylammonium chloride (C.I. Basic Violet 3)
561-41-1 4,4'-bis(dimethylamino)-4''-(methylamino)trityl alcohol) New on Version 8.0
56-35-9 Bis(tributyltin)oxide (TBTO)
573-58-0 Disodium 3,3'-[[1,1'-biphenyl]-4,4'-diylbis(azo)]bis(4-aminonaphthalene- New on Version 8.1
1-sulphonate) (C.I. Direct Red 28)
59653-74-6 β-TGIC (1,3,5-tris[(2S and 2R)-2,3-epoxypropyl]-1,3,5-triazine-2,4,6- New on Version 8.0
(1H,3H,5H)-trione)
5-sec-butyl-2-(2,4- 5-sec-butyl-2-(2,4-dimethylcyclohex-3-en-1-yl)-5-methyl-1,3-dioxane New on Version 8.2
dimethylcyclohex-3-en-1-yl)-5-
methyl-1,3-dioxane
5-sec-butyl-2-(4,6- 5-sec-butyl-2-(4,6-dimethylcyclohex-3-en-1-yl)-5-methyl-1,3-dioxane New on Version 8.2
dimethylcyclohex-3-en-1-yl)-5-
methyl-1,3-dioxane
60-09-3 4-Aminoazobenzene; 4-Phenylazoaniline New on Version 8.0
605-50-5 Diisopentylphthalate New on Version 8.0
62229-08-7 Sulfurous acid, lead salt, dibasic New on Version 8.0
625-45-6 Methoxy acetic acid New on Version 8.0
629-14-1 1,2-Diethoxyethane New on Version 8.0
64-67-5 Diethyl sulphate New on Version 8.0
6477-64-1 Lead dipicrate New on Version 8.0
65996-93-2 Pitch, coal tar, high temp
6786-83-0 α,α-Bis[4-(dimethylamino)phenyl]-4 (phenylamino)naphthalene-1- New on Version 8.0
methanol (C.I. Solvent Blue 4)
68-12-2 N,N-dimethylformamide; dimethyl formamide New on Version 8.0
683-18-1 Dibutyltin dichloride (DBT) New on Version 8.0
68515-42-4 1,2-Benzenedicarboxylic acid, di-C7-11-branched and linear alkyl esters New on Version 8.0
68515-50-4 1,2-Benzenedicarboxylic acid, dihexyl ester, branched and linear New on Version 8.1
68515-51-5 1,2-Benzenedicarboxylic acid, di-C6-10-alkyl esters with ≥ 0.3% of New on Version 8.2
dihexyl phthalate
68648-93-1 1,2-Benzenedicarboxylic acid, mixed decyl and hexyl and octyl diesters New on Version 8.2
with ≥ 0.3% of dihexyl phthalate
68784-75-8 Silicic acid, barium salt, lead-doped New on Version 8.0
69011-06-9 [Phthalato(2-)]dioxotrilead New on Version 8.0
71-48-7 Cobalt(II) diacetate New on Version 8.0
71888-89-6 1,2-Benzenedicarboxylic acid, di-C6-8-branched alkyl esters, C7-rich New on Version 8.0
72629-94-8 Pentacosafluorotridecanoic acid New on Version 8.0

7440-43-9 Cadmium New on Version 8.1
75-12-7 Formamide New on Version 8.0
75-56-9 Propylene oxide; 1,2-epoxypropane; methyloxirane New on Version 8.0
7632-04-4 Sodium peroxometaborate New on Version 8.1
7646-79-9 Cobalt dichloride
77-09-8 Phenolphthalein New on Version 8.0
7738-94-5 Acids generated from chromium trioxide and their oligomers. Group New on Version 8.0
containing: Chromic acid, Dichromic acid, Dichromic acid, Oligomers of
chromic acid and dichromic acid
7758-97-6 Lead chromate
776297-69-9 N-pentyl-isopentylphtalate New on Version 8.0
7775-11-3 Sodium chromate
77-78-1 Dimethyl sulphate New on Version 8.0
7778-39-4 Arsenic acid New on Version 8.0
7778-44-1 Calcium arsenate New on Version 8.0
7778-50-9 Potassium dichromate
7784-40-9 Lead hydrogen arsenate
7789-00-6 Potassium chromate
7789-06-2 Strontium chromate New on Version 8.0
7789-09-5 Ammonium dichromate
7789-12-0 Sodium dichromate
7790-79-6 Cadmium fluoride New on Version 8.1
78-00-2 Tetraethyllead New on Version 8.0
7803-57-8 Hydrazine New on Version 8.0
79-01-6 Trichloroethylene
79-06-1 Acrylamide
79-16-3 N-methylacetamide New on Version 8.0
80-05-7 4,4'-isopropylidenediphenol Bisphenol A; BPA New on Version 8.3
8012-00-8 Pyrochlore, antimony lead yellow New on Version 8.0
80-46-6 p-(1,1-dimethylpropyl)phenol New on Version 8.3
81-15-2 5-tert-butyl-2,4,6-trinitro-m-xylene (musk xylene)
838-88-0 4,4'-methylenedi-o-toluidine New on Version 8.0
84-69-5 Diisobutyl phthalate
84-74-2 Dibutyl phthalate
84-75-3 Dihexyl phthalate New on Version 8.1
84777-06-0 1,2-Benzenedicarboxylic acid, dipentylester, branched and linear New on Version 8.0
85-42-7 cyclohexane-1,2-dicarboxylic anhydride, Hexahydro-2-benzofuran-1,3- New on Version 8.0
dione (HHPA)
85535-84-8 Alkanes, C10-13, chloro (Short Chain Chlorinated Paraffins)
85-68-7 Benzyl butyl phthalate
872-50-4 1-Methyl-2-pyrrolidone New on Version 8.0
88-85-7 Dinoseb New on Version 8.0
90-04-0 2-Methoxyaniline; o-Anisidine New on Version 8.0
90640-80-5 Anthracene Oil
90640-81-6 Anthracene oil, anthracene paste
90640-82-7 Anthracene oil, anthracene-low
90-94-8 4,4'-bis(dimethylamino)benzophenone (Michler’s ketone) New on Version 8.0
91031-62-8 Fatty acids, C16-18, lead salts New on Version 8.0
91995-15-2 Anthracene oil, anthracene paste, anthracene fraction
91995-17-4 Anthracene oil, anthracene paste, distn. Lights
92-67-1 Biphenyl-4-ylamine New on Version 8.0
95-53-4 o-Toluidine; 2-Aminotoluene New on Version 8.0
95-80-7 4-methyl-m-phenylenediamine (2,4-toluene-diamine) New on Version 8.0
96-18-4 1,2,3-Trichloropropane New on Version 8.0
96-45-7 Imidazolidine-2-thione; (2-imidazoline-2-thiol) New on Version 8.1
97-56-3 o-aminoazotoluene New on Version 8.0
98-95-3 Nitrobenzene New on Version 8.2
Form-A Exemptions Exemption Description Expiration / Details

1(a):Mercury Mercury in single capped (compact) fluorescent lamps not exceeding Expires on 31 December 2011; 3,5 mg may be
(per burner): For general lighting purposes < 30 W: 5 mg used per burner after 31 December 2011 until 31
December 2012; 2,5 mg shall be used per
burner after 31 December 2012
1(b):Mercury Mercury in single capped (compact) fluorescent lamps not exceeding Expires on 31 December 2011; 3,5 mg may be
(per burner): For general lighting purposes = 30 W and < 50 W: 5 mg used per burner after 31 December 2011
1(c):Mercury Mercury in single capped (compact) fluorescent lamps not exceeding

(per burner): For general lighting purposes = 50 W and < 150 W: 5 mg
1(d):Mercury Mercury in single capped (compact) fluorescent lamps not exceeding

(per burner): For general lighting purposes = 150 W: 15 mg
1(e):Mercury Mercury in single capped (compact) fluorescent lamps not exceeding No limitation of use until 31 December 2011; 7
(per burner): For general lighting purposes with circular or square mg may be used per burner after 31 December
structural shape and tube diameter = 17 mm 2011
1(f):Mercury Mercury in single capped (compact) fluorescent lamps not exceeding
(per burner): For special purposes: 5 mg
1(g):Mercury Mercury in single capped (compact) fluorescent lamps not exceeding Expires on 31 December 2017
(per burner): For general lighting purposes <30 W with lifetime equal or
above 20 000 h: 3,5 mg
2(a)(1):Mercury Mercury in double-capped linear fluorescent lamps for general lighting Expires on 31 December 2011; 4 mg may be
purposes not exceeding (per lamp): Tri-band phosphor with normal used per lamp after 31 December 2011
lifetime and a tube diameter < 9 mm (e.g. T2): 5 mg
lifetime and a tube diameter = 9 mm and = 17 mm (e.g. T5): 5 mg
2(a)(3):Mercury Mercury in double-capped linear fluorescent lamps for general lighting Expires on 31 December 2011; 3,5 mg may be
lifetime and a tube diameter > 17 mm and = 28 mm (e.g. T8): 5 mg
2(a)(4):Mercury Mercury in double-capped linear fluorescent lamps for general lighting Expires on 31 December 2012; 3,5 mg may be
lifetime and a tube diameter > 28 mm (e.g. T12): 5 mg
purposes not exceeding (per lamp): Tri-band phosphor with long lifetime used per lamp after 31 December 2011
(= 25000 h): 8 mg
2(b)(3):Mercury Mercury in other fluorescent lamps not exceeding (per lamp): Non-linear No limitation of use until 31 December 2011; 15
tri-band phosphor lamps with tube diameter > 17 mm (e.g. T9) mg may be used per lamp after 31 December
2011
2(b)(4):Mercury Mercury in other fluorescent lamps not exceeding (per lamp): Lamps for No limitation of use until 31 December 2011; 15
other general lighting and special purposes (e.g. induction lamps) mg may be used per lamp after 31 December
2011
3(a):Mercury Mercury in cold cathode fluorescent lamps and external electrode No limitation of use until 31 December 2011; 3,5
fluorescent lamps (CCFL and EEFL) for special purposes not exceeding mg may be used per lamp after 31 December
(per lamp): Short length (= 500 mm) 2011
3(b):Mercury Mercury in cold cathode fluorescent lamps and external electrode No limitation of use until 31 December 2011; 5
(per lamp): Medium length (> 500 mm and = 1500 mm) 2011
3(c):Mercury Mercury in cold cathode fluorescent lamps and external electrode No limitation of use until 31 December 2011; 13
(per lamp): Long length (> 1500 mm) 2011
4(a):Mercury Mercury in cold cathode fluorescent lamps and external electrode No limitation of use until 31 December 2011; 15
(per lamp): Mercury in other low pressure discharge lamps (per lamp) 2011
4(b)-I:Mercury Mercury in High Pressure Sodium (vapour) lamps for general lighting No limitation of use until 31 December 2011; 30
purposes not exceeding (per burner) in lamps with improved colour mg may be used per burner after 31 December
rendering index Ra > 60: P = 155 W 2011
4(b)-II:Mercury Mercury in High Pressure Sodium (vapour) lamps for general lighting No limitation of use until 31 December 2011; 40
rendering index Ra > 60: 155 W < P = 405 W 2011
4(b)-III:Mercury Mercury in High Pressure Sodium (vapour) lamps for general lighting No limitation of use until 31 December 2011; 40
rendering index Ra > 60: P > 405 W 2011
4(c)-I:Mercury Mercury in other High Pressure Sodium (vapour) lamps for general No limitation of use until 31 December 2011; 25
lighting purposes not exceeding (per burner): P = 155 W mg may be used per burner after 31 December
2011
4(c)-II:Mercury Mercury in other High Pressure Sodium (vapour) lamps for general No limitation of use until 31 December 2011; 30
lighting purposes not exceeding (per burner): 155 W < P = 405 W mg may be used per burner after 31 December
2011
4(c)-III:Mercury Mercury in other High Pressure Sodium (vapour) lamps for general No limitation of use until 31 December 2011; 40
lighting purposes not exceeding (per burner): P > 405 W mg may be used per burner after 31 December
2011
4(e):Mercury Mercury in metal halide lamps (MH)
4(f):Mercury Mercury in other discharge lamps for special purposes not specifically
mentioned in this Annex
4(g):Mercury Mercury in hand crafted luminous discharge tubes used for signs, Expires on 31 December 2018
decorative or architectural and specialist lighting and light-artwork,
where the mercury content shall be limited as follows: (a) 20 mg per
electrode pair + 0,3 mg per tube length in cm, but not more than 80 mg,
for outdoor applications and indoor applications exposed to
temperatures below 20 °C; (b) 15 mg per electrode pair + 0,24 mg per
tube length in cm, but not more than 80 mg, for all other indoor
applications.
5(a):Lead Lead in glass of cathode ray tubes

5(b):Lead Lead in glass of fluorescent tubes not exceeding 0,2 % by weight
6(a):Lead Lead as an alloying element in steel for machining purposes and in
galvanized steel containing up to 0,35 % lead by weight
6(b):Lead Lead as an alloying element in aluminium containing up to 0,4 % lead by
weight
6(c):Lead Copper alloy containing up to 4 % lead by weight
7(a):Lead Lead in high melting temperature type solders (i.e. lead-based alloys
containing 85 % by weight or more lead)
7(b):Lead Lead in solders for servers, storage and storage array systems, network Expires on 21 July 2016 and after that date
infrastructure equipment for switching, signalling, transmission, and may be used in spare parts for EEE placed on
network management for telecommunications the market before 21 July 2016
7(c)-I:Lead Electrical and electronic components containing lead in a glass or
ceramic other than dielectric ceramic in capacitors, e.g. piezoelectronic
devices, or in a glass or ceramic matrix compound
7(c)-II:Lead Lead in dielectric ceramic in capacitors for a rated voltage of 125 V AC
or 250 V DC or higher
7(c)-IV:Lead Lead in PZT based dielectric ceramic materials for capacitors being part
of integrated circuits or discrete semiconductors
8(b):Cadmium Cadmium and its compounds in electrical contacts
9:Hexavalent chromium Hexavalent chromium as an anticorrosion agent of the carbon steel
cooling system in absorption refrigerators up to 0,75 % by weight in the
cooling solution
9(b):Lead Lead in bearing shells and bushes for refrigerant-containing
compressors for heating, ventilation, air conditioning and refrigeration
(HVACR) applications
13(a):Lead Lead in white glasses used for optical applications
13(b):Cadmium Cadmium and lead in filter glasses and glasses used for reflectance
standards
15:Lead Lead in solders to complete a viable electrical connection between
semiconductor die and carrier within integrated circuit flip chip packages
17:Lead Lead halide as radiant agent in high intensity discharge (HID) lamps
used for professional reprography applications
18(b):Lead 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)
21:Lead and Cadmium Lead and cadmium in printing inks for the application of enamels on
glasses, such as borosilicate and soda lime glasses
24:Lead Lead in solders for the soldering to machined through hole discoidal and
planar array ceramic multilayer capacitors
25:Lead Lead oxide in surface conduction electron emitter displays (SED) used
in structural elements, notably in the seal frit and frit ring
29:Lead Lead bound in crystal glass as defined in Annex I (Categories 1, 2, 3
and 4) of Council Directive 69/493/EEC [1]
30:Cadmium 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 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 Lead oxide in seal frit used for making window assemblies for Argon and
Krypton laser tubes
33:Lead Lead in solders for the soldering of thin copper wires of 100 µm diameter
and less in power transformers
34:Lead Lead in cermet-based trimmer potentiometer elements
37:Lead Lead in the plating layer of high voltage diodes on the basis of a zinc
borate glass body
38:Cadmium Cadmium and cadmium oxide in thick film pastes used on aluminium
bonded beryllium oxide
41:Lead Lead in solders and termination finishes of electrical and electronic Expires on 31 December 2018
components and finishes of printed circuit boards used in ignition
modules and other electrical and electronic engine control systems,
which for technical reasons must be mounted directly on or in the
crankcase or cylinder of hand-held combustion engines (classes SH:1,
SH:2, SH:3 of Directive 97/68/EC of the European Parliament and of the
Council(*)

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NOTE: DO NOT DELETE THIS CONTROL WORKSHEET FROM THE FILE,

General Instructions for Completing the EHS-1001 Declaration Form

Supplier Internal Breakdowns or Alternate Parts

Instructions for common fields.

Xerox Part Number [Required]

Supplier Identifier [Optional]

Form EHS-1001A Banned Substances (completion required)

2.3 RoHS Exemption (Column H) [Required]

2.3 Percentage by weight (Column I) [Optional]

2.3 Batteries [Required]

EHS-1001A Example for Supplier Internal Breakdowns or Alternate Parts

Example of Supplier Alternate Parts for same Xerox Part Number

Form EHS-1001B Reportable Substance (completion required)

EHS-1001B Example for Supplier Internal Breakdowns or Alternate Parts

Example of Supplier Alternate Parts for same Xerox Part Number

> This is an example of what should NOT be done:

Form EHS-1001C REACH (completion required)

EHS-1001C Example for Supplier Internal Breakdowns or Alternate Parts

Example of Supplier Alternate Parts for same Xerox Part Number

Xerox Form EHS-1001 A Supplier Certification of Compliance, version 8.3

A.3.ii Batteries-If part

Xerox Form EHS-1001 B Supplier Use of "Reportable" Substances, version 8.3

Xerox Part Number - part numbers

Xerox Form EHS-1001 C Supplier Use of REACH Substances, version 8.3

Xerox Part Number - part numbers

Xerox Part Number - part numbers

Xerox Part Number - part numbers

24613-89-6 Dichromium tris(chromate) New on Version 8.0

25973-55-1 2-(2H-benzotriazol-2-yl)-4,6-ditertpentylphenol (UV-328) New on Version 8.1

4149-60-4 Ammonium salts of perfluorononan-1-oic-acid New on Version 8.2

48122-14-1 Hexahydro-1-methylphathalic anhydride (MHHPA) New on Version 8.0

49663-84-5 Pentazinc chromate octahydroxide New on Version 8.0

50-32-8 Benzo[def]chrysene (Benzo[a]pyrene) New on Version 8.3

72629-94-8 Pentacosafluorotridecanoic acid New on Version 8.0

Form-A Exemptions Exemption Description Expiration / Details

1(c):Mercury Mercury in single capped (compact) fluorescent lamps not exceeding

1(d):Mercury Mercury in single capped (compact) fluorescent lamps not exceeding

5(a):Lead Lead in glass of cathode ray tubes

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