5900-182 Home Performance Homeowner Satisfaction Form

OMB Control No. xxxx-xxxx

During the past three months energy efficiency improvements were completed on your home by

<contractor name> . To help us evaluate the quality of work performed by contractors that participate in the Home Performance with ENERGY STAR program please complete our short (3 questions) customer satisfaction form. You can complete this form online at: http://www.energystar.gov/feedback

CUSTOMER SATISFACTION FORM

Contactor Name: ____________________

1. How satisfied were you with the following aspects of the work you had done.

Check the appropriate box.

	Very Satisfied	Satisfied	Dissatisfied	Very Dissatisfied	Unknown or Not Applicable
Information from initial energy audit	G	G	G	G	G
Listened to my concerns and goals	G	G	G	G	G
Explanation of work to be done and why	G	G	G	G	G
Quality of work done	G	G	G	G	G
Speed and timeliness of work	G	G	G	G	G
Clean up after work done	G	G	G	G	G
Overall satisfaction with work done	G	G	G	G	G

2. How did you hear abut this contractor?

G Web site

G Referral from friend/family

G TV ad

G Radio ad

G Newspaper ad

G Yellow pages

G Other (please describe) ________________________________________

____________________________________________________________

3. Would you recommend this contractor or Home Performance with ENERGY STAR to a friend?

G Yes

G No

Please share any comments or concerns about your experience. ____________________________________________________________________________

____________________________________________________________________________

Home Performance with ENERGY STAR is a program sponsored by the U.S Environmental Protection Agency and the U.S. Department of Energy. For more information visit www.energystar.gov.

EPA Form 5900-182

The government estimates the average time needed to fill out this form is 0.05 hours and welcomes suggestions for reducing this effort. Send comments (referencing OMB Control Number) to the Director, Collection Strategies Division, U.S. EPA (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460.