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

without any debug or changes to the product.

Test (PT) 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 test

Yes 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:

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

Basket Transfer Time

(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)
Power Requirements (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

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:
Frequency Sine tones
Frequency/ 2
PSD (g /Hz or (Amplitude-
Frequency (m/s2)2/Hz) / Acceleration
range Slope (dB/Oct) (g) /
(Broad Band) Displacement
(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
Frequency (m/s2)2/Hz) / Frequency or
range Slope (dB/Oct) range (m/s2)2/Hz)
(Broad Band) (Narrow Band)

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

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:

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:

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

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
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 6 of 6