GU6-RS500GXUHF RFID Module

TCRFIDRCD Rev. 00 8/14 ©2014 Avery Dennison Corp. All rights reserved. REGULATORY COMPLIANCE INFORMATION The RS-500 (Impinj model number IPJ-RS500-GX) is approved for modular certification by FCC and Industry Canada (IC) under the following ID numbers: FCC ID: GU6-RS500GX IC: 1502A-RS500GX Modular approval allows installation in different end-use products by an original equipment manufacturer (OEM) with limited or no additional testing or equipment authorization for the transmitter function provided by the RS500. In addition, the end product must comply with all applicable FCC equipment authorizations, regulations, requirements and equipment functions not associated with the RS500. For example, compliance must be demonstrated to regulations for other transmitter components within the host product, to requirements for unintentional radiators (Part 15B), and to additional authorization requirements for the non-transmitter functions. The OEM applying the RS500 is required to include all FCC and/or IC statements and warnings detailed in the following sections to the end product labeling (where specified) and in the finished product manual. The OEM must also strictly adhere to antenna and installation guidelines and MPE restrictions stated in this document. Product Labeling A statement must be included on the exterior of the final OEM product which communicates that the device identified by the aforementioned FCC and Industry Canada ID numbers are contained within the product. For example: This product contains a radio module certified as FCC ID: GU6-RS500GX and IC: 1502A-RS500GX OR Contains FCC ID: GU6-RS500GX Contains IC: 1502A-RS500GX The OEM must include the following statements on the exterior of the finished product unless the product is too small (e.g. less than 4 x 4 inches): This device complies with Part 15 of the FCC Rules. Operation is subject to the following two conditions: (1) this device may not cause harmful interference, and (2) this device must accept any interference received, including any interference that may cause undesired operation. DRAFT 2 Product Manuals US Requirements The finished product manual must contain the following statement: WARNING: The Federal Communications Commission warns that changes or modifications of the radio module within this device not expressly approved by the manucaturer could void the user’s authority to operate the equipment. I n the case where an OEM seeks class B (residential) limits for the host product, the finished product manual must contain the following statement: Note: This equipment has been tested and found to comply with the limits for a Class B digital device, pursuant to part 15 of the FCC Rules. These limits are designed to provide reasonable protection against harmful interference in a residential installation. This equipment generates, uses and can radiate radio frequency energy and, if not installed and used in accordance with the instructions, may cause harmful interference to radio communications. However, there is no guarantee that interference will not occur in a particular installation. If this equipment does cause harmful interference to radio or television reception, which can be determined by turning the equipment off and on, the user is encouraged to try to correct the interference by one or more of the following measures: ♦ Reorient or relocate the receiving antenna. ♦ Increase the separation between the equipment and receiver. ♦ Connect the equipment into an outlet on a circuit different from that to w hich the receiver is connected. ♦ Consult the dealer or an experienced radio/TV technician for help. In the case where an OEM seeks the lesser category of a Class A digital device for their finished product, the following statement must be included in the manual of the finished product: Note: This equipment has been tested and found to comply with the limits for a Class A digital device, pursuant to part 15 of the FCC Rules. These limits are designed to provide reasonable protection against harmful interference when the equipment is operated in a commercial environment. This equipment generates, uses, and can radiate radio frequency energy and, if not installed and used in accordance with the instruction manual, may cause harmful interference to radio communications. Operation of this equipment in a residential area is likely to cause harmful interference in which case the user will be required to correct the interference at his expense. DRAFT 3 Canadian Requirements The OEM must include the following regulatory statements (shown in italics) in both English and French on the exterior of the finished product and/or in the product manual: This device complies with Industry Canada license-exempt RSS standard(s). Operation is subject to the following two conditions: (1) this device may not cause interference, and (2) this device must accept any interference, including interference that may cause undesired operation of the device. Le présent appareil est conforme aux CNR d'Industrie Canada applicables aux appareils radio exempts de licence. L'exploitation est autorisée aux deux conditions suivantes : (1) l'appareil ne doit pas produire de brouillage, et (2) l'utilisateur de l'appareil doit accepter tout brouillage radioélectrique subi, même si le brouillage est susceptible d'en compromettre le fonctionnement. The OEM must include the following regulatory statements (shown in italics) in both English and French in the finished product manual: Under Industry Canada regulations, this radio transmitter may only operate using an antenna of a type and maximum (or lesser) gain approved for the transmitter by Industry Canada. To reduce potential radio interference to other users, the antenna type and its gain should be so chosen that the equivalent isotropically radiated power (e.i.r.p.) is not more than that necessary for successful communication. This radio transmitter IC: 1502A-RS500GX has been approved by Industry Canada…

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775 Montague Expressway Milpitas, CA 95035 Tel: 408-526-1188 Fax: 408-526-1088 Email: [email protected] Modular Approval Declaration Letter Reason for Amendment (current / obsolete) Revision History Approved Date From To Initial Release (Obsolete) 1.0 1.0 Dec-04-2006 Added IC Modular Letter (Obsolete) 1.0 2.0 Feb 16 2009 Add LMA and MA option (Obsolete) 2.0 3.0 April 14 2010 Revised per RSS Gen issue 3.0 (Obsolete) 3.0 4.0 Jan 12 2011 Removed Foot(2) (obsolete) 4.0 5.0 July 19 2011 Adding New note per KDB996369 D01 V01R03 (obsolete) 5.0 6.0 August 29 2011 Updated company template & Added text box (current) 6.0 7.0 Jan-31-2012 SCS-F26 Modular Approval Letter Page 2 of 3 Rev 7.0 7/14/2014 (Product name) FCC ID : GU6-RS500GX , is seeking FCC Authorization as a Single Modular transmitter / Single Limited Modular Approval (Please check one). The EUT meets the requirements for Single Modular approval / Single Limited Modular Approval (please check one) as detailed in FCC public Notice DA00-1407. Compliance to each of the requirements is described below: Questions are: * Please provide a detailed explanation if the answer is “No.” 1. “The modular transmitter must have its own RF shielding.” Yes / No 2. “The modular transmitter must have buffered modulation/data inputs.” Yes / No 3. “The modular transmitter must have its own power supply regulation.” Yes / No 4. “The modular transmitter must comply with the antenna requirements of section 15.203 and 15.204(c).” Yes / No 5. “The modular transmitter must be tested in a stand-alone configuration.” Yes / No 6. “The modular transmitter must be labeled with its own FCC ID number.” Yes / No 7. “The modular transmitter must comply with any specific rule or operating requirements applicable to the transmitter and the manufacture must provide adequate instruction along with the module to explain any such requirements.” Yes / No 8. “The modular transmitter must comply with any applicable RF exposure requirements.” Yes / No Note: (1) LMA may be granted when one or more of the requirements in the table above cannot be demonstrated. LMA will also be issued in those instances where applicants can demonstrate that they will retain control over the final installation of the device, such that compliance of the end product is assured. In such cases, an operating condition on the LMA for the module must state that the module is only approved for use when installed in devices produced by a specific manufacturer. When LMA is sought, the application for equipment certification must specifically state how control of the end product into which the module will be installed, and will be maintained, such that full compliance of the end product is always ensured. (2) Please provide Clear and specific instructions describing the conditions, limitations and procedures for third-parties to use and/or integrate the module into a host device. (3) For non-Software Defined Radio transmitter modules where software is used to ensure compliance of the device, technical description of how such control is implemented to ensure prevention of third party modification must be provided (see KDB 594280). Note 1: Compliance of a module in its final configuration is the responsibility of the applicant. A host device will not be considered certified if the instructions regarding antenna configuration provided in the original description, of one or more separately certified modules it contains, were not followed. Example: A separately certified low-power transceiver module using Bluetooth technology which is housed in a desktop computer, laptop or peripheral does not require the overall system to be recertified, if the desktop computer, laptop or peripheral, as a stand-alone unit, complies with all applicable technical standards. James Bacher Avery Dennison RIS LLC 170 Monarch Lane Miamisburg, OH 45342 PH: 937-865-2020 / Fax: 937-865-2048 [email protected] SCS-F26 Modular Approval Letter Page 3 of 3 Rev 7.0 170 Monarch Lane Miamisburg, OH 45342 Phone 1.937.865.2123 Fax: 1.937.865.2048 LMA Declaration Letter We, Avery Dennison RIS LLC, declare that we will retain control over the final installation of the device, (FCC ID: GU6-RS500GX) such that compliance of the end product is assured. In such cases, an operating condition on the LMA for the module must be only approved for use when installed in devices produced by a specific manufacturer. James Bacher Avery Dennison RIS LLC 170 Monarch Lane Miamisburg, OH 45342 PH: 937-865-2020 / Fax: 937-865-2048 [email protected]

775 Montague Expressway Milpitas, CA 95035 Tel: 408-526-1188 Fax: 408-526-1088 Email: [email protected] Project and Product Certification Representative Authorization Letter Reason for Amendment (current / obsolete) Revision History Approved Date From To Initial Release (obsolete) 1.0 1.0 Nov-14-2006 Revised wording (obsolete) 1.0 2.0 Sept–25-2007 Updated company template (obsolete) 2.0 3.0 Jan-31-2012 Updated letter information (current) 3.0 4.0 May-23-2014 SCS-F18: Project and Product Certification Representative Authorization Letter Page 2 of 2 Rev 4.0 170 Monarch Lane Miamisburg, OH 45342 Phone 1.937.865.2123 Fax: 1.937.865.2048 7/14/2014 To: SIEMIC, Inc. 775 Montague Expressway, Milpitas, CA 95035 USA Dear Sir/Madam, Re: Project and Product Certification Representative Authorization Letter We, Avery Dennison Retail Information Services, LLC, hereby authorize SIEMIC, Inc. to act as Certification Body for certifying for the following project(s): FCC ID: GU6-RS500GX Product Description: UHF RFID Module Model: RS500GX We affirm that between SIEMIC, Inc. and Avery Dennison Retail Information Services, LLC, any difference in understanding, including test plan, measurement methods, applicable standards and relevant procedures and processes have been resolved prior to commencement of testing activities. Sincerely, James Bacher Avery Dennison RIS LLC 170 Monarch Lane Miamisburg, OH 45342 PH: 937-865-2020 / Fax: 937-865-2048 [email protected]

775 Montague Expressway Milpitas, CA 95035 Tel: 408-526-1188 Fax: 408-526-1088 Email: [email protected] Confidentiality Request Letter Reason for Amendment (current / obsolete) Revision History Approved Date From To Initial Release (obsolete) 1.0 1.0 Nov-14-2006 Adding CFR 2.459 (obsolete) 1.0 2.0 August – 11 - 2008 Updated company template & Added text box (current) 2.0 3.0 Jan-31-2012 SCS-F19: Confidentiality Request Letter Page 2 of 2 Rev 3.0 170 Monarch Lane Miamisburg, OH 45342 Phone 1.937.865.2123 Fax: 1.937.865.2048 7/14/2014 To: Federal Communications Commission Authorization and Evaluation Division 7435 Oakland Mills Road Columbia, MD Subject: Permanent Confidentiality Request for FCC ID: GU6-RS500GX We hereby request confidential treatment of information accompanying this application as outlined below: - Block Diagram - Schematics - Operational Description The above materials contain trade secrets and proprietary information not customarily released to the public. The public disclosure of these materials may be harmful to the applicant and provide unjustified benefits to its competitors. The applicant understands that pursuant to Section 0.457 & 0.459 of the Rules, disclosure of this application and all accompanying documentation will not be made before the date of the Grant for this application. Sincerely, James Bacher Avery Dennison RIS LLC 170 Monarch Lane Miamisburg, OH 45342 PH: 937-865-2020 / Fax: 937-865-2048 [email protected]

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MPE CALCULATION FCC ID: GU6-RS500GX / IC ID: 1502A-RS500GX RF Exposure Requirements: 47 CFR §1.1307(b) RF Radiation Exposure Limits: 47 CFR §1.1310 RF Radiation Exposure Guidelines: FCC OST/OET Bulletin Number 65 EUT Frequency Band: 902.75-927.25 MHz, 2402-2480 MHz, 2412 - 2462 MHz; 5180 - 5825MHz Limits for General Population/Uncontrolled Exposure in the band of: 300-1500 MHz, 1500 - 100,000 MHz Power Density Limit: 0.62 mW / cm 2 (300-1500 MHz), 1 mW / cm 2 (2402-2480 MHz, 2412 - 2462 MHz; 5180 - 5825MHz) Equation: S = PG / 4R 2 or R = √PG / 4S Where, S = Power Density P = Power Input to Antenna G = Antenna Gain R = distance to the center of radiated antenna ______________________________________________________________________________________________________________________ Prediction distance 20cm WLAN N radio (2412-2462MHz): Power = 22.38 dBm , antenna gain = 1.0 dBi , Power density = 0.0433 mW/cm 2 WLAN N radio (5180-5825MHz): Power = 22.97 dBm, antenna gain = 1.1 dBi, Power density = 0.0508 mW/cm 2 UHF RFID (902.75-927.25MHz): Power = 19.85 dBm, Antenna gain= -12dBi, Power density=0.0012 mW/cm 2 RFID and WLAN radio can work simultaneously, so the total ratio of MPE is, Total Ratio of WLAN radio 2.4GHz + RFID = (P RFID /0.62)+(P WLAN /1) = 0.0433 /1 + 0.0012 /0.62 = 0.0452 < 1 Total Ratio of WLAN radio 5GHz + RFID = (P RFID /0.62)+(P WLAN /1) = 0.0508 /1 + 0.0012 /0.62 = 0.0527 < 1 Maximum MPE is 0.0527, which is less than 1. The Above Result had shown that Device complied with MPE requirement. Completed By : David Zhang Date : Jan 29th, 2014

775 Montague Expressway, Milpitas, CA 95035, USA • Phone: (+1) 408 526 1188 • Facsimile (+1) 408 526 1088 Visit us at: www.siemic.com e Report No.: FCC_RF_SL13092401 Supersede Report No.: FCC_RF_SL13092401 Applicant Avery Dennison Product Name RFID module Model No. RS500GX Test Standard 47CFR15.247, RSS- Test Method ANCI C63.4:2009 47CFR15.247, RSS- FCC ID GU6-RS500GX IC ID 1502A-RS500GX Date of test 11/26/2013 - 12/31/2013 Issue Date 8/11/2014 Test Resut Pass Equipment complied with the specification Equipment did not comply with the specification David Zhang Test Engineer This test report may be reproduced in full only Test result presented in this test report is applicable to the tested sample only 775 Montague Expressway, Milpitas, 95035 CA RF TEST REPORT 775 Montague Expressway, Milpitas, CA 95035, USA • Phone: (+1) 408 526 1188 • Facsimile (+1) 408 526 1088 www.siemic.com; Follow us at: FCC_RF_SL13092401-AVE-031_RFID Rev2.1 FCC_RF_SL13092401-AVE-031_RFID Rev2.0 -210 Issue8: 2010 -210 Issue8: 2010 12/31/2013 Fail Equipment complied with the specification [ x ] Equipment did not comply with the specification [ ] Nima Molaei Engineer Reviewer This test report may be reproduced in full only Test result presented in this test report is applicable to the tested sample only Issued By: SIEMIC Laboratories 775 Montague Expressway, Milpitas, 95035 CA 775 Montague Expressway, Milpitas, CA 95035, USA • Phone: (+1) 408 526 1188 • Facsimile (+1) 408 526 1088 Nima Molaei Engineer Reviewer Test result presented in this test report is applicable to the tested sample only 775 Montague Expressway, Milpitas, CA 95035, USA • Phone: (+1) 408 526 1188 • Facsimile (+1) 408 526 1088 Visit us at: www.siemic.com Laboratory Introduction SIEMIC, headquartered in the heart of Silicon Valley, with superior facilities in US and Asia, is one of the leading independent test and certification facilities providing customers with one In addition to testing and certification, SIEMIC provides initial design reviews and extensive experience with China, Asia Pacific fastest, most cost effective way to attain regulatory compliance for the Accreditations for Conformity Assessment Country/Region Accreditation Body USA Canada Taiwan Hong Kong Australia Korea Japan VCCI, JATE, TELEC, RFT Mexico NOM, COFETEL, Caniety Europe Accreditations for Product Certifications Country Accreditation Body USA Canada Singapore EU Japan HongKong Test report No. FCC_RF_SL13092401 Page 2 of 44 775 Montague Expressway, Milpitas, CA 95035, USA • Phone: (+1) 408 526 1188 • Facsimile (+1) 408 526 1088 www.siemic.com; Follow us at: Laboratory Introduction headquartered in the heart of Silicon Valley, with superior facilities in US and Asia, is one of the leading independent test and certification facilities providing customers with one3stop shop services for Compliance Testing and Global Certifications. , SIEMIC provides initial design reviews and compliance management Asia Pacific, North America, European, and International compliance requirements, assures the fastest, most cost effective way to attain regulatory compliance for the global markets. Accreditations for Conformity Assessment Accreditation Body Scope FCC, A2LA EMC , RF/Wireless , Telecom IC, A2LA, NIST EMC, RF/Wireless , Telecom BSMI , NCC , NIST EMC, RF, Telecom , Safety OFTA , NIST RF/Wireless ,Telecom NATA, NIST EMC, RF, Telecom , Safety KCC/RRA, NIST EMI, EMS, RF , Telecom, Safety VCCI, JATE, TELEC, RFT EMI, RF/Wireless, Telecom NOM, COFETEL, Caniety Safety, EMC , RF/Wireless, A2LA, NIST EMC, RF, Telecom , Safety Accreditations for Product Certifications Accreditation Body Scope FCC TCB, NIST EMC , RF , Telecom IC FCB , NIST EMC , RF , Telecom iDA, NIST EMC , RF , Telecom NB EMC & R&TTE Directive MIC (RCB 208) RF , Telecom OFTA (US002) RF , Telecom FCC_RF_SL130924013AVE3031_RFID Rev.2.1 775 Montague Expressway, Milpitas, CA 95035, USA • Phone: (+1) 408 526 1188 • Facsimile (+1) 408 526 1088 headquartered in the heart of Silicon Valley, with superior facilities in US and Asia, is one of the leading independent testing stop shop services for Compliance Testing and Global Certifications. compliance management throughout a project. Our compliance requirements, assures the Scope EMC , RF/Wireless , Telecom EMC, RF/Wireless , Telecom EMC, RF, Telecom , Safety RF/Wireless ,Telecom EMC, RF, Telecom , Safety EMI, EMS, RF , Telecom, Safety EMI, RF/Wireless, Telecom Safety, EMC , RF/Wireless, Telecom EMC, RF, Telecom , Safety Scope EMC , RF , Telecom EMC , RF , Telecom EMC , RF , Telecom EMC & R&TTE Directive RF , Telecom RF , Telecom 775 Montague Expressway, Milpitas, CA 95035, USA • Phone: (+1) 408 526 1188 • Facsimile (+1) 408 526 1088 Visit us at: www.siemic.com CONTENTS 1 REPORT REVISION HISTORY ................................ 2 EXECUTIVE SUMMARY ................................ 3 CUSTOMER INFORMATION ................................ 4 TEST SITE INFORMATION ................................ 5 MODIFICATION ................................ 6 EUT INFORMATION ................................ 6.1 EUT Description ................................ 6.2 Radio Description ................................ 6.3 EUT test modes/configuration Description 6.4 EUT Photos 3 External ................................ 6.5 Host Photos 3 External ................................ 6.6 EUT Test Setup Photos ................................ 7 SUPPORTING EQUIPMENT/SOFTWARE AND CABLIN 7.1 Supporting Equipment ................................ 7.2 Test Software Description ................................ 8 TEST SUMMARY ................................ 9 MEASUREMENT UNCERTAINTY ................................ 10 MEASUREMENTS, EXAMINATION AND DERIVED RE 10.1 Antenna Requirement................................ 10.2 Conducted Emissions ................................ 10.3 20dB Bandwidth ................................ 10.4 99% Occupied Bandwidth ................................ 10.5 Number of Hopping Channel 10.6 Peak Out…

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AC Line Conducted Emissions – Front View AC Line Conducted Emissions – Rear View Radiated Emissions (<1GHz) – Front View Radiated Emissions (<1GHz) – Rear View Radiated Emissions (>1GHz) – Front View Radiated Emissions (>1GHz) – Rear View