TEST REQUEST FORM
ENVIRONMENTAL
Customer Details
Applicant Name
Address
Contact Person
Phone/Mobile E-mail
Report to be issued to:
(Name and Address of the customer)
Product Details
Product Name
Brief Product Description
Product Dimensions (W*D*H) mm
Weight Of the Product (Kg)
Number of Samples
Model Number / Part Number
Serial Number
Heat Dissipation of the EUT (in Watts)
Fixture Details & Accessories: Thermal Tests (If applicable) Vibration (if applicable)
Fixture Dimensions (W*D*H) mm
Fixture Weight (Kg)
Fixture Dimensions
Projected Date of Sample submission
Environmental Vibration Shock / Bump IP
Test Requirement
Salt Spray Drop Test
Automotive Avionics Consumer Electronics
Industrial Information Technology Laboratory
Category Medical Telecom Naval Lighting
Railway Military Consumer/Household
Others (please specify) _________________
International / National Standard (Specify)
Test Method Customer Specification (Specify)
Others (Specify)
Type of Service Customer can carry out customized tests for
debug purpose and changes on the product to fix
Development
identified issues, if any. No formal test report will
Test (DT)
be issued from the lab. Test data and graphs will
be provided to customer, if feasible
Performance Test is carried out as per the specified standard
Prepared By: Purimitla Vemana Approved By: Sathisha C. N Issued By: Krishna Deori
Document No: LAB_F(EE)_140-001 Issue No.: 01 Issued On: 02/07/2024 Revision No.: 00 Revision Date: --/--/--- Page 1 of 6
TEST REQUEST FORM
ENVIRONMENTAL
Test (PT) without any debug or changes to the product.
This is a Qualification test. A formal test report
will be issued by the lab at the end of the test.
Is test report required? Yes No
If yes, select criteria to be used for Statement of
conformity
Measurement result reported considering test
limit according to the specification in standard.
Measurement result reported, considering
Yes test limits specified by customer specification.
Is a Statement of Conformity
Required?
Measurement result reported, considering
test limits according to the specification
mentioned in the standard and Measurement
Uncertainty (Acceptance Criteria= Simple
Acceptance and as per ILAC-G8:09)
Will report the measured result / physical
No
Verification
Note: In case of Quantitative analysis, lab will preferably consider the uncertainty of measurement for decision
rules, until not prescribed by customer.
Measurement Uncertainty required Yes No
Mention specific storage conditions if any
Required accessories/
Yes No Item: Quantity:
auxiliary equipment/cables etc. are
submitted
Witness can be the customer or customer’s
Test witness Yes No
representative.
Continue testing in case of any test
Yes No
failure?
By customer within 30 working days
Sample collection after completion of
testing Dispatch by courier to customer (at customer’s cost)
External Service (Sub-contract) required Yes No
Test Specifications: Environmental
Temperature & Humidity Standard / Clause No.: If any Attachment
Temperature / Thermal Shock / Humidity / Tropical Exposure / Damp Heat / Damp Heat Cyclic:
Standard (s) / Customer
Specific:
Temperature (°C):
Humidity (%RH):
Dwell Time:
Ramp Rate:
Basket Transfer Time
Prepared By: Purimitla Vemana Approved By: Sathisha C. N Issued By: Krishna Deori
Document No: LAB_F(EE)_140-001 Issue No.: 01 Issued On: 02/07/2024 Revision No.: 00 Revision Date: --/--/--- Page 2 of 6
TEST REQUEST FORM
ENVIRONMENTAL
(Thermal Shock)
Number of cycles:
EUT Condition
EUT Pre-Test Verification
(If applicable):
EUT Post-Test Verification
(If applicable)
Power Requirements
(If applicable):
Altitude / Combined Altitude Temperature Humidity Test / Low Pressure Test:
Standard (s) / Customer Specific:
Temperature (°C):
Altitude Test (mbar):
Humidity (%RH):
Dwell Time:
Ramp Rate:
EUT Condition:
EUT Pre-Test Verification (If
applicable):
EUT Post-Test Verification (If
applicable)
Power Requirements (If
applicable):
Vibration Standard / Clause No.: If any Attachment
Sine Vibration Test:
Test Specification:
Amplitude
Frequency/ Frequency range
(Acceleration/ Displacement)
No of sweeps / Duration:
Sweep Rate:
No of axis:
EUT Condition:
EUT Pre-Test Verification (If
applicable):
EUT Post-Test Verification (If
applicable)
Prepared By: Purimitla Vemana Approved By: Sathisha C. N Issued By: Krishna Deori
Document No: LAB_F(EE)_140-001 Issue No.: 01 Issued On: 02/07/2024 Revision No.: 00 Revision Date: --/--/--- Page 3 of 6
TEST REQUEST FORM
ENVIRONMENTAL
Power Requirements (If
applicable):
Random Vibration Test:
Test Specification:
PSD (g2/Hz or (m/s2)2/Hz) /
Frequency/ Frequency range
Slope (dB/Oct)
No of axis:
EUT Condition:
EUT Pre-Test Verification (If applicable):
EUT Post-Test Verification (If applicable)
Power Requirements (If applicable):
Site-On-Random Vibration Test:
Test Specification:
Frequenc Sine tones
Frequency/ PSD (g /Hz or
2
y (Amplitude-
Frequency (m/s2)2/Hz) / Acceleration
range Slope (dB/Oct) (g) /
(Broad Band) Displacemen
t (mm))
No of axis:
EUT Condition:
EUT Pre-Test Verification (If applicable):
EUT Post-Test Verification (If applicable)
Power Requirements (If applicable):
Random-On-Random Vibration Test:
Test Specification:
Frequency/ PSD (g2/Hz or Frequency/ PSD (g2/Hz
Prepared By: Purimitla Vemana Approved By: Sathisha C. N Issued By: Krishna Deori
Document No: LAB_F(EE)_140-001 Issue No.: 01 Issued On: 02/07/2024 Revision No.: 00 Revision Date: --/--/--- Page 4 of 6
TEST REQUEST FORM
ENVIRONMENTAL
Frequency (m/s2)2/Hz) / Frequency or
range Slope range (m/s2)2/Hz)
(Broad Band) (dB/Oct) (Narrow Band)
No of axis:
EUT Condition:
EUT Pre-Test Verification (If applicable):
EUT Post-Test Verification (If applicable)
Power Requirements (If applicable):
Mechanical Shock / Bump Test:
Acceleration Level (G / (m/s2)):
Pulse Width (ms):
Number of Shocks / Bumps:
Bumps per second:
Number of axis:
EUT Condition:
EUT Pre-Test Verification (If applicable):
EUT Post-Test Verification (If applicable):
Power Requirements (If applicable):
IP Standard / Clause No.: If any Attachment
Protection against access to Hazardous Parts / Dust:
IP1X: IP2X: IP3X: IP4X: IP5X (Dust): IP6X (Dust)
EUT Condition:
EUT Pre-Test Verification (If applicable):
EUT Post-Test Verification (If applicable)
Power Requirements (If applicable):
Protection against water:
IPX1 IPX2 IPX3 IPX4 IPX5 IPX6 IPX7 IPX8: IPX9K
EUT Condition:
Prepared By: Purimitla Vemana Approved By: Sathisha C. N Issued By: Krishna Deori
Document No: LAB_F(EE)_140-001 Issue No.: 01 Issued On: 02/07/2024 Revision No.: 00 Revision Date: --/--/--- Page 5 of 6
TEST REQUEST FORM
ENVIRONMENTAL
EUT Pre-Test Verification (If applicable):
EUT Post-Test Verification (If applicable)
Power Requirements (If applicable):
Salt /Corrosion /Cyclic Corrosion Standard / Clause No.: If any Attachment
Salt Spray / Corrosion / Cyclic Corrosion Test:
Temperature (°C):
Humidity (%RH):
Fog Collection / Spray Rate:
Dwell Time:
Number of Cycles:
EUT Condition:
EUT Pre-Test Verification (If applicable):
EUT Post-Test Verification (If applicable)
Power Requirements (If applicable):
Drop Standard / Clause No.: If any Attachment
Drop Test:
Drop Height:
Number of Drops:
Number of Flap / Edge Drop:
EUT Condition:
EUT Pre-Test Verification (If applicable):
EUT Post-Test Verification (If applicable)
Power Requirements (If applicable):
To be Filled by Lab
Condition of samples on receipt Good Bad (Inform to customer)
Capability and resources are available to Yes No
meet the test requirements
External Service (Sub-contract) required Yes No
Probable commencement date
Prepared By: Purimitla Vemana Approved By: Sathisha C. N Issued By: Krishna Deori
Document No: LAB_F(EE)_140-001 Issue No.: 01 Issued On: 02/07/2024 Revision No.: 00 Revision Date: --/--/--- Page 6 of 6
TEST REQUEST FORM
ENVIRONMENTAL
Probable completion date
Acceptance of contract by Customer Acceptance of service by Lab
Name Name
Designation Designation
Signature & Date Signature & Date
Prepared By: Purimitla Vemana Approved By: Sathisha C. N Issued By: Krishna Deori
Document No: LAB_F(EE)_140-001 Issue No.: 01 Issued On: 02/07/2024 Revision No.: 00 Revision Date: --/--/--- Page 7 of 6
