GREEN BUILDING MATERIAL LEED DATA FORM

Project: ___________________________
Architect: ___________________________

CSI Specification Section: __________________________ Product: ____________________________

Supplier / Sub-contractor: __________________________ Manufacturer: ____________________________
Contact Person: __________________________ Contact Person: ____________________________
Tel. No.: __________________________ Tel. No.: ____________________________
Fax No.: __________________________ Fax No.: ____________________________
www. __________________________ www. ____________________________

Product Certification
Tick applicable credit compliance and fill out the required information.

I. MR CREDIT: BUILDING PRODUCT DISCLOSURE AND OPTIMIZATION

A. Environmental Product Declarations (EPD)

Please select the available EPD of the product as attached in this submittal:
 Publicly available life-cycle assessment with cradle to gate scope conforming to ISO 14044
 Type III EPD with cradle to gate scope:
Please select the EPD category: EPD conforms to the following (choose all that applies):
 Industry-wide (generic)  ISO 14025  EN 15804
 Product-specific  ISO 14040  ISO 21930
 ISO 14044
 Other USGBC approved program (please specify): ____________________________
 This product has no available document to comply with this criterion.
B. Multi-Attribute Optimization
Please select the available Multi-Attribute Optimization certification as attached in this submittal:
 Third-party certified LCA demonstrating impact reduction below industry average from the following a
a categories (choose at least three):
 Global warming potential (greenhouse gases), in CO e; 2

 Depletion of the stratospheric ozone layer, in kg CFC-11;

 Acidification of land and water sources, in moles H+ or kg SO ; 2

 Eutrophication, in kg nitrogen or kg phosphate;

 Formation of tropospheric ozone, in kg NO , kg O eq., or kg ethene; and
x 3

 Depletion of nonrenewable energy resources, in MJ

 Other USGBC approved program (please specify): ____________________________
 This product has no available document to comply with this criterion.

Green Building Material LEED Data Form page 1 of 6

Form developed by Arcadis Philippines, Inc. Do not reproduce without prior permission
 GREEN BUILDING MATERIAL LEED DATA FORM
Project: ___________________________
Architect: ___________________________

CSI Specification Section: __________________________ Product: ____________________________

Supplier / Sub-contractor: __________________________ Manufacturer: ____________________________
Contact Person: __________________________ Contact Person: ____________________________
Tel. No.: __________________________ Tel. No.: ____________________________
Fax No.: __________________________ Fax No.: ____________________________
www. __________________________ www. ____________________________

C. Raw Material Source & Extraction Reporting

Please select the available extraction report as attached in this submittal (choose one):
 Publicly-released self-declared reports which includes raw material extraction location from the supplier
 Third-party verified corporate sustainability report or CSR (choose one):
 Global Reporting Initiative (GRI) Sustainability Report
 Organization for Economic Cooperation and Development (OECD) Guidelines for Multinational aaa
aaaa Enterprises
 U.N. Global Compact: Communication of Progress
 ISO 26000: 2010 Guidance on Social Responsibility
 Other USGBC approved program (please specify): ____________________________
 This product has no available document to comply with this criterion.
D. Leadership Extraction Practices
Please select if the manufacturer complies to any responsible extraction criteria below with supporting
documents as attached in this submittal (choose all that applies):
 This product is produced by a manufacturer who engages in an extended producer responsibility.
 This is a bio-based product which meets the Sustainable Agriculture Network’s Sustainable a a a a a a
a Agriculture Standard with raw materials tested under ASTM Test Method D6866.
 This is a wood product certified by the Forest Stewardship Council (FSC) or USGBC approved a a a a
a equivalent.
 This product is made from reused materials as salvaged or refurbished.
 This product has recycled content:
Description of Recycled Content:
Percentage of Post-Consumer (PO) Recycled Content:
Percentage of Pre-Consumer (PR) Recycled Content:

 Other USGBC approved program (please specify): ____________________________

 This product has no available document to comply with this criterion.

Green Building Material LEED Data Form page 2 of 6

Form developed by Arcadis Philippines, Inc. Do not reproduce without prior permission
 GREEN BUILDING MATERIAL LEED DATA FORM
Project: ___________________________
Architect: ___________________________

CSI Specification Section: __________________________ Product: ____________________________

Supplier / Sub-contractor: __________________________ Manufacturer: ____________________________
Contact Person: __________________________ Contact Person: ____________________________
Tel. No.: __________________________ Tel. No.: ____________________________
Fax No.: __________________________ Fax No.: ____________________________
www. __________________________ www. ____________________________

E. Material Ingredient Reporting

Please select the available and attached chemical inventory report (with at least 0.1%, 1000ppm) from
the following (choose all that applies):
 A publicly-available inventory of all ingredients identified by name and Chemical Abstract Service a a
a aRegistration Number (CASRN)
Note: If this product has materials defined as trade secret or intellectual property, the name and/or CASRN may a
a be withheld but must disclose role, amount and GreenScreen benchmark, as defined in GreenScreen v1.2.

 Health Product Declaration with full disclosure of known hazards in compliance with the HPD Open b
b b Standard
 Cradle to Cradle Certification (choose one):
 v2 Basic level  v3 Bronze level  Higher level of Certification (please specify): ______________

 Other USGBC approved program (please specify): ____________________________

 This product has no available document to comply with this criterion.
F. Material Ingredient Optimization
Please select the available material ingredient optimization report with supporting document as attached
in this submittal (choose all that applies):
 Full inventory of chemical ingredients to 100ppm which have no Benchmark 1 hazards under a a a a a
a a GreenScreen v1.2
 Cradle to Cradle Certification (choose one):
 v2 Gold  v2 Platinum  v3 Silver  v3 Gold  v3 Platinum
 REACH Certification
 Other USGBC approved program (please specify): ____________________________
 This product has no available document to comply with this criterion.

Green Building Material LEED Data Form page 3 of 6

Form developed by Arcadis Philippines, Inc. Do not reproduce without prior permission
 GREEN BUILDING MATERIAL LEED DATA FORM
Project: ___________________________
Architect: ___________________________

CSI Specification Section: __________________________ Product: ____________________________

Supplier / Sub-contractor: __________________________ Manufacturer: ____________________________
Contact Person: __________________________ Contact Person: ____________________________
Tel. No.: __________________________ Tel. No.: ____________________________
Fax No.: __________________________ Fax No.: ____________________________
www. __________________________ www. ____________________________

G. Regional Material

○ All components of the product were extracted, harvested or recovered (source i.e. mining a site),
a manufactured (i.e. plant), and purchased within 1 00 miles (160 km) of the project site.

Harvest Location:
Harvest Distance (Encircle unit used: mi I km)
Manufacture Location:
Manufacture Distance (Encircle unit used: mi / km)

 A certification from the manufacturer is attached to provide supporting document to the above
a a declaration.
○ A portion of this product was extracted, harvested or recovered (source i.e. mining site), a a a a
a manufactured (i.e. plant), or purchased more than 1 00 miles (160 km) of the project site.

II. EQ CREDIT: LOW-EMITTING MATERIALS

Please select the applicable product category:

○ ADHESIVE* ○ CEILING INSULATION
○ SEALANT* ○ WALL INSULATION
○ PAINT* ○ THERMAL INSULATION
○ COATING* ○ ACOUSTIC INSULATION
○ FLOORING ○ NOT APPLICABLE
 This product is an inherently non-emitting source of VOCs. Hence, VOC Testing and Emissions a a a
a Evaluation are no longer required.

A. VOC Content

*For wet applied products only: Please provide the VOC content:
VOC Content (in g/L)

Green Building Material LEED Data Form page 4 of 6

Form developed by Arcadis Philippines, Inc. Do not reproduce without prior permission
 GREEN BUILDING MATERIAL LEED DATA FORM
Project: ___________________________
Architect: ___________________________

CSI Specification Section: __________________________ Product: ____________________________

Supplier / Sub-contractor: __________________________ Manufacturer: ____________________________
Contact Person: __________________________ Contact Person: ____________________________
Tel. No.: __________________________ Tel. No.: ____________________________
Fax No.: __________________________ Fax No.: ____________________________
www. __________________________ www. ____________________________

 A separate submittal data sheet is attached as supporting document:

 Material safety data sheet (MSDS)
 VOC Test Report
 Technical data sheet / manufacture data sheet
 Others (please specify): _________________________
B. General Emissions Evaluation
Please select the available emissions test report as attached in this submittal (choose all that applies):

 CDPH Standard Method 2010

 German AgBB Testing and Evaluation Scheme 2010
 ISO 16000-3: 2010, ISO 16000-6: 2011, ISO 16000-9: 2006, ISO 16000-11: 2006
 DIBt Testing Method 2010
○ COMPOSITE WOOD ○ NOT APPLICABLE
Please provide the formaldehyde concentration of this product:

Formaldehyde concentration (in ppm or mg/m2-h)

Please select the available emissions test report as attached in this submittal (choose all that applies):
 EN-717-1: 2004
 CEN/TS 16516: 2013
 ISO 16000-3: 2010, ISO 16000-6: 2011, ISO 16000-9: 2006, ISO 16000-11: 2006
 Belgian or French legislation on VOC emission class labeling in conjunction with AgBB
○ FURNITURE ○ NOT APPLICABLE
 This product has been tested in accordance to ANSI/BIFMA Standard Method M7.1-2011 as attached in this a
a submittal.

Green Building Material LEED Data Form page 5 of 6

Form developed by Arcadis Philippines, Inc. Do not reproduce without prior permission
 GREEN BUILDING MATERIAL LEED DATA FORM
Project: ___________________________
Architect: ___________________________

CSI Specification Section: __________________________ Product: ____________________________

Supplier / Sub-contractor: __________________________ Manufacturer: ____________________________
Contact Person: __________________________ Contact Person: ____________________________
Tel. No.: __________________________ Tel. No.: ____________________________
Fax No.: __________________________ Fax No.: ____________________________
www. __________________________ www. ____________________________

Manufacturer Certification
CERTIFIED BY (Manufacturer):

Print Name: _____________________________

Signature: _____________________________
Title: _____________________________
Date: _____________________________

Installer Certification
For Low-Emitting Materials: Please select the area of application of the product (choose all that applies):
 Interior  Exterior
Total Installed Material Volume: _____________________________
Total Installed Material Cost (Less Labor and Equipment): _____________________________

CERTIFIED BY (Contractor):

Print Name: _____________________________

Signature: _____________________________
Title: _____________________________
Date: _____________________________

Green Building Material LEED Data Form page 6 of 6

Form developed by Arcadis Philippines, Inc. Do not reproduce without prior permission