Raw Material Information Form (RMIF)
CONFIDENTIAL
VENDOR NAME:PRODUCT TRADENAME:
Expera JDE ID Number*
*To be completed by Expera after approval of item.
Requirements: Expera requires suppliers to provide the following information requested on this form to enable us to ensure that Expera products containing your material will comply with global regulatory requirements. Please add any pertinent comments directly to this form rather than sending back multiple documents. Do not omit any sections of this form and please make sure all sections are completed and all boxes are checked or noted as N/A.
This document is required in addition to the Safety Data Sheet - (M)SDS
In addition, if there are any changes to your material, changes to the manufacturing processes that may affect the material in the future, or a change in the regulatory compliance status, you acknowledge and agree to re-submit this document with the applicable changes and updated (M)SDS to your Expera Contact. This includes changes in (subcontracted) manufacturers or the manufacturing location for a product. If you are not the manufacturer but are a distributor of the product, a separate RMIF form should be completed for each manufacturer.
Please complete and return this document to the Expera Contact initiating the request.
Prepared by:
Supplier Regulatory or Health/ Safety ContactName:
Position:
Address:
Phone:
Fax:
E-Mail:
Signed:
Date:
Please list the manufacturer’s name for this product:
Guarantee:
The product listed above comprising each shipment or other delivery hereafter made by the Supplier is hereby guaranteed as of the date of such shipment or delivery, to be on such date, not adulterated or misbranded within the meaning of the Federal Food, Drug and Cosmetic Act, and not an article which may not, under the provisions of Section 404(Emergency Permit Control) of the Act be introduced into interstate commerce.
Please indicate below and attach all relevant documentation to substantiate the
information on this form. Such documentation should include:
Safety Data Sheet (M)SDS (Required)
Supplier Product Specifications (Required)
Product Technical Data Sheet (storage, handling, disposal) (If available)
Chemical Composition
Please complete the table below, listing the chemical names and CAS numbers for all of the components in your finished product. In the comment section please indicate whether this is an active ingredient, residual by-product, or unintended trace impurity.
CAS # / Chemical Name / % by weight / CommentsTSCA Status
Is this material and its components in compliance with the requirements of the TSCA Chemical Substance Inventory. Yes No Exempt
If your material is exempt because it is an article, regulated by FIFRA, FDA, R&D Exemption, etc., please check Exempt box.
Is the product subject to any Test Rule, Consent Order, Significant New Use Rule (SNUR), allegations of significant adverse health or environmental reactions, or Ban under TSCA Yes No
Please explain:
Origin of Manufacture (for NAFTA reporting)
Where is the material manufactured – specify country?
If the material is imported, will Expera be considered the importer of record for this material? Yes No
ISO Certification
ISO 9001 / Yes NoISO 14001 / Yes No
Please attach current ISO certificate.
GMP Certification: Standard Certified to/compliant with :
______
Certificate date:______Certifying Body:______
(Blank = none)
FDA
Does this product comply with FDA 21 CFR? Yes No
Please list all parts with which the material complies and any limitations:
Part / Restrictions/LimitationsIf complaint with part 176.170, what conditions from table 2 apply to your product?
Please provide your compliance (noncompliance) statement:
Commission Regulation (EC) Compliance
EC 1935/2004? Yes No
EC 2023/2006? Yes No
EC 1895/2005? Yes No Not Applicable
BfR
Does this product comply with BfR XXXVI, Paper and board for food contact? Yes No
If yes, please identifySection, Paragraph and Subparagraph number
Does this product comply with BfR XXXVI/2, Paper and paperboard for baking purposes? Yes No
If yes, please identifySection, Paragraph and Subparagraph number
Proposition 65
Does this product contain substances listed under the Safe Drinking Water and Toxic Enforcement Act of 1986? Yes No
If yes, please list the items.
CAS # / % Weight / Orppm / Comments: Please supply data source, detection limits or safe harbour assessment
Kosher
Is this product Kosher Certified? Yes No
Is this product Kosher for Passover Certified? Yes No
· If yes, please attach a copy of the Kosher certificate indicating the certifying organization and expiration date
· If no, you may be requested to send a letter of positive derivation to OK Kosher.
RoHS or ROHS recast and CONEG
CAS # / % by weight / Comments: Please supply chemical nameCadmium and Cadmium Compounds / Yes No
Hexavalent Chromium (Cr VI) Compounds / Yes No
Lead and Lead Compounds / Yes No
Mercury and Mercury Compounds / Yes No
Phthalates / Yes No
Brominated flame retardants (PBB’s or PBDE’s) / Yes No
Chemicals of Concern:
Please indicate if your material contains any of the following above the minimum level of detection, or if any of the following are used in the manufacture of your product by you or your suppliers if so, identify the amount contained in weight %.
CAS # / % by weight / Comments: Please supply chemical nameAntimony/Antimony Compounds / Yes No
Arsenic/Arsenic Compounds / Yes No
Beryllium/Beryllium Compounds / Yes No
Bismuth/Bismuth Compounds / Yes No
Copper/Copper Compounds / Yes No
Nickel/Nickel Compounds / Yes No
Selenium/Selenium Compounds / Yes No
Silver/Silver Compounds / Yes No
Zinc/Zinc Compounds / Yes No
Asbestos / Yes No
Azo colorants / Yes No
Bisphenol A & Bisphenol A compounds / Yes No
Alkylphenol/ Alkylphenolethoxylates (AP/APE)? / Yes No
Nonyl Phenol Ethoxylate (NPE) / Yes No
Formaldehyde / Yes No
Halogenated Compounds (Specify which)
Bromine____ Chlorine_____
Fluorine______Iodine_____ / Yes No
Materials of human or animal origin / Yes No
Genetically Modified Materials (GMOs) / Yes No
Melamine / Yes No
Ozone Depleting Substances / Yes No
PFOS / PFOA / Yes No
Polyaromatic Hydrocarbons (PAHs) / Yes No
Natural Rubber or Natural Rubber Latex / Yes No
Crystalline Silica / Yes No
Silicone / Yes No
Vinyl Chloride Polymer (PVC) / Yes No
Volatile Organic Carbon (VOC) Compounds – List individual components and weight % / Yes No
Triclosan (2,4,4’-trichloro-2’-hydroxydiphenyl ether) / Yes No
Mineral oil Aromatic Hydrocarbons or Mineral oil Saturated Hydrocarbons (MOAH or MOSH) / Yes No
Does this product contain any substances regulated as a state and/or federal hazardous or conventional air pollutant? (Above the threshold amounts of 0.1% for known or potential carcinogens and 1% for non carcinogens listed on NR445 Table A, Wisconsin Administrative Code and/or the Clean Air Act hazardous air pollutant list). Yes No
· If yes, indicate substance(s) and concentration -
Other Regulations:
Question / Yes or No / CAS # / % Weight / Orppm / Comments: Please supply data source and detection limits where possible?
Does the material contain any chemicals listed by EPCRA Section 313- Toxics Release Inventory? / Yes No
Does the material contain any chemicals listed by the Stockholm Convention on Persistent Organic Pollutants (POPs Treaty) / Yes No
Does this product contain substances listed under the Canadian Environmental Act (CEPA Challenge), Batches 1 through 12? / Yes No
Does this product contain Substances of Very High Concern (SVHC) listed currently under REACH? / Yes No
Does this product contain substances listed under REACH Annex XIV? / Yes No
Does this product contain substances listed under REACH Annex XVII? / Yes No
Does this product contain substances listed under Conflict Minerals in section 1502 of the Dodd-Frank Wall Street Reform and Consumer Protection Act of 2010 (Dodd-Frank Act). / Yes No
Does this product contain substances listed under Toy Safety? / Yes No
Does this product contain substances listed under GADSL? / Yes No
Do you have a CFIA file number for this product? If yes, please add it in the comments section / Yes No
Is material considered hazardous by Canadian WHMIS? / Yes No
Does your company comply with California Transparency in Supply Chains Act (SB 657 Slavery and Human Trafficking)? / Yes No
Allergens
Please indicate if your material contains any of the following and the amount contained in the material in weight % or ppm, ppb as appropriate.
Question / Yes or No / CAS # / % Weight / Orppm / Comments: Please supply chemical name and detection limits where possible?
Does this product contain substances listed on the Food Allergen Labeling and Consumer Protection Act of 2004: milk, egg, fish, crustacean shellfish, tree nuts, wheat, peanuts, soybeans. / Yes No
Celery – Celery or celery derivatives, etc. / Yes No
Sulfur Dioxide & Sulfites at any concentrations. / Yes No
Wood-Based Materials
If you supply wood-based materials including Pulp, Paper, Wood or Paper-based packaging materials such as wrapper, headers, cores, labels, pallets, etc., this section must also be completed.Sustainable Forestry
Are you FSC/SFI/PEFC COC certified? List type of certification and certificate number, and attach copy of your certificate. For non-certified sources, a controlled wood risk assessment must be included.
Dioxins and furans
The results reported should be based on EPA method 1613B or equivalent
Please state the TDE (total dioxin equivalent) and date of result.
Chlorine
Is your product ECF (Elemental Chlorine Free) or TCF (Total Chlorine Free)?
Is your product Peroxide Free?
Please describe your bleaching sequence.
Lacey Act, EUTR, Australian Illegal Logging Prohibition Act
Please provide compliance statements for the above laws or any other illegal logging compliance information.
AQ – Do you use Anthroquinone in your pulping process?
Please list all components and % composition for materials in your product. For fiber-based materials, please list the fiber species and Country of Harvest for each material.
Please list any non-virgin fiber materials used to manufacture your product and % composition, including
% same-site pre-consumer waste (broke)
% pre-consumer waste
% post-consumer waste
Revision 05-15-17