OMB Control Number: 1910-5151
HOUSING UNIT INFORMATION SURVEY
This survey collects detailed information about homes weatherized (or waitlisted) by your agency that have been selected for analysis by the national evaluation. The data you supply will be used with billing history data to better understand energy savings attributable to the Weatherization Assistance Program.
Please use this form to provide information about any single family detached and attached houses, mobile homes, or individual units within multi-family buildings. The Building Information Survey should be used to document information on small or large multifamily buildings in which the whole building and all units in the building were weatherized or are waitlisted. Refer to the definitions of each building type provided at the end of the survey because these definitions are slightly different than those commonly used within the Weatherization Assistance Program.
Public reporting burden for this collection of information is estimated to average forty hours per weatherization agency, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Office of the Chief Information Officer, Records Management Division, IM-11, Paperwork Reduction Project (1910-5151), U.S. Department of Energy, 1000 Independence Ave SW, Washington, DC, 20585-1290; and to the Office of Management and Budget (OMB), OIRA, Paperwork Reduction Project (1910-5151), Washington, DC 20503.
All of the information obtained from this survey will be protected and will remain confidential. The data will be analyzed in such a way that the information provided cannot be associated back to your state, your agencies, or the housing units and clients that your state served.
Form completed by: ______________________________ Date: _______________
Unit identification number (to be completed by the evaluation team): _______________
IDENTIFICATION
1. Subgrantee (agency) name: ________________________________________
2. State: _______________
3. Agency job number: ____________________
4. Occupant name: ______________________________
5. Site address: ______________________________ 6. City: ___________________________
7. If this home is currently waitlisted, check here and complete only the Housing Unit and Household sections below.
WEATHERIZATION INFORMATION
Weatherization dates (not audit or inspection dates):
8a. Started: __________ __________ __________
8b. Completed:__________ __________ __________
(month) (day) (year)
9. Was this a “reweatherized” unit? (check only one)
Yes
No
Don’t know
10. Does the housing unit meet your state’s definition for being a high residential energy user? (check only one)
Yes
No
No state definition in place
Don’t know
11. Does the housing unit meet your state’s definition for being a household with a high energy burden? (check only one)
Yes
No
No state definition in place
Don’t know
12. Did this client file a complaint about the weatherization services you provided? (check only one) Yes
No
Don’t know
HOUSING UNIT
13. Building type – see definitions at end of form: (check only one)
Single-family detached house
Single-family attached house (e.g., side-by-side duplex, townhouse, row house)
Single-family – unknown whether attached or detached
Mobile home
Small multifamily building (2-4 units per building and not a SF attached house)
Large multifamily building (5 or more units per building and not a SF attached house)
Shelter
Don’t know
14. If single-family detached or attached, number of stories above grade: (check only one)
1
2
3
4 or more
Don’t know
Not applicable
15. If single-family attached, number of units attached (adjacent) to this unit: (check only one)
1
2
3
4 or more
Don’t know
Not applicable
16. If mobile home, number of rooms that have been added on: (check only one)
None
1
2
3
4 or more
Don’t know
Not applicable
17. If small or large multifamily building, number of units in the building: (check only one)
2
3
4
5-9
10-19
20-29
30-49
50-99
100 or more
Don’t know
Not applicable
18. Ownership (check only one)
Owner occupied
Rental
Other (specify: ____________________ )
Don’t know
19. Year house/building originally built: (check only one)
2000 or later
1990 to 1999
1980 to 1989
1970 to 1979
1960 to 1969
1950 to 1959
1940 to 1949
1930 to 1939
1920 to 1929
1910 to 1919
1900 to 1909
Before 1900
Don’t know
Conditioned floor area at the time of weatherization: (include the basement only if it is intentionally conditioned)
20a. Heated floor area: _________ ft² Don’t know
20b. Air conditioned floor area: __________ft² Don’t know
21. Primary fuel used to heat the unit during the winter before weatherization: (check only one)
Natural gas
Propane/LPG
Kerosene (#1 fuel oil)
Fuel oil (#2 fuel oil)
Electricity
Wood
Coal
Other (specify: ____________________)
Don’t know
22. Type of primary space-heating system before weatherization: (check only one)
Central (ducted) warm-air furnace (forced-air or gravity, any fuel including electricity)
Heat pump
Built-in electric units (e.g., electric baseboards, ceiling heat)
Steam or hot water system (e.g., floor or baseboard radiators, convectors)
Floor, wall, or pipeless (ductless) furnace (e.g., floor or wall furnace)
Room/space heater (nonportable)
Portable space heater
Cooking stove
None
Don’t know
23. If small or large multifamily building, was the primary space-heating system shared with other housing units? (check only one)
Yes
No
Don’t know
Not applicable
24. Supplemental fuel used to heat the unit during the winter before weatherization: (check all that apply)
Natural gas
Propane/LPG
Kerosene (#1 fuel oil)
Fuel oil (#2 fuel oil)
Electricity
Wood
Other (specify: ____________________)
None
Don’t know
25. Type of operable air conditioning system present before weatherization: (check all that apply)
Central air conditioner/heat pump
Window/wall units
Evaporative cooling system (“swamp coolers”)
None
Don’t know
26. Number of window/wall air conditioning units: (check only one)
None
1
2
3
4 or more
Don’t know
Electric utility information:
27a. Name: ____________________ Don’t know
27b. Account number: ____________________ Don’t know
Natural gas utility information:
28a. Natural gas not installed in house
28b. Name: ____________________ Don’t know
28c. Account number: ____________________ Don’t know
HOUSEHOLD
29. Household annual income (as used to determine Program eligibility): $__________ per year
30. Total number of occupants: (check only one)
1
2
3
4
5
6
7
8
9 or more
Don’t know
31. Check if the housing unit was occupied by at least one person who was: (check all that apply)
Elderly (60 or older)
Disabled
Native American
A child (as defined by your state)
32. Number of children (as defined by your state): (check only one)
None
1
2
3
4
5 or more
Don’t know
33. Number of elderly (60 or older): (check only one)
None
1
2
3
4
5 or more
Don’t know
34. Number of disabled : (check only one)
None
1
2
3
4
5 or more
Don’t know
35. Year moved into housing unit: (check only one)
2007
2008
2005
2000 to 2004
1995 to 1999
1990 to 1994
1985 to 1989
1980 to 1984
1975 to 1979
1970 to 1974
1965 to 1969
1960 to 1964
1955 to 1959
1950 to 1954
Before 1950
Don’t know
36. Is the household headed by a single parent? (check only one)
Yes
No
Don’t know
37. Race and ethnicity of the head of household: (check all that apply)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Hispanic or Latino
Don’t know
AUDIT
38. Primary method used to select weatherization measures for this house (excluding health, safety, and repair measures and general heat waste measures): (check only one)
Priority list
Calculation procedure (e.g., spreadsheet, computerized audit)
Other (specify: ____________________ )
39. If a calculation procedure was used, the name of the procedure(s): (check all that apply)
AK Warm
EA-3
EASY
EA-QUIP
HomeCheck
Meadows
REES
REM/Rate
SMOC-ERS
TIPS
TREAT
Weatherization Assistant (NEAT/MHEA)
WXEOR
Other (specify: ____________________ )
Not applicable
DIAGNOSTICS AND INSPECTIONS
Indicate which of the following diagnostic measurements and inspections were performed by your agency on THIS housing unit and when they were performed: (check all that apply)
Diagnostic measurement or inspection |
Diagnostic/inspection performed during: |
||
|
Audit/house assessment |
Measure installation |
Post-inspection |
Pressure diagnostics: |
|
|
|
40a. Blower door measurement (house air leakage rate) |
|
|
|
40b. Zonal pressure |
|
|
|
40c. Room-to-room pressures (distribution system balancing) |
|
|
|
40d. Duct pressure pan measurements |
|
|
|
40e. Duct blower measurement (duct air leakage rate) |
|
|
|
40f. Blower door subtraction meas. (duct air leakage rate) |
|
|
|
|
|
|
|
Space-heating system: |
|
|
|
41a. Flue gas analysis (steady-state efficiency measurement) |
|
|
|
41b. Heat rise |
|
|
|
41c. CO level in flue |
|
|
|
41d. CO level of equipment room |
|
|
|
41e. Draft/spillage (normal operation) |
|
|
|
41f. Worst case draft/spillage (CAZ) |
|
|
|
41g. Safety inspection |
|
|
|
|
|
|
|
Air-conditioning system: |
|
|
|
42a. Refrigerant charge (e.g., superheat or subcooling) |
|
|
|
42b. Safety inspection |
|
|
|
|
|
|
|
HVAC components: |
|
|
|
43a. Air handler flow rate |
|
|
|
43b. Thermostat anticipator current |
|
|
|
|
|
|
|
Diagnostic measurement or inspection |
Diagnostic/inspection performed during: |
||
|
Audit/house assessment |
Measure installation |
Post-inspection |
Hot-water (water-heating) system: |
|
|
|
44a. Flue gas analysis (steady-state efficiency measurement) |
|
|
|
44b. CO level in flue |
|
|
|
44c. CO level of equipment room |
|
|
|
44d. Draft/spillage (normal operation) |
|
|
|
44e. Worst case draft/spillage (CAZ) |
|
|
|
44f. Hot water temperature |
|
|
|
44g. Shower head flow rate |
|
|
|
44h. Faucet flow rate |
|
|
|
44i. Safety inspection |
|
|
|
|
|
|
|
Other CO measurements: |
|
|
|
45a. Cook stove |
|
|
|
45b. Kitchen |
|
|
|
45c. Main living area |
|
|
|
|
|
|
|
Other diagnostics and inspections: |
|
|
|
46a. Refrigerator energy use |
|
|
|
46b. Exhaust fan air flow rate |
|
|
|
46c. Infrared scanning (camera) |
|
|
|
46d. Radon testing |
|
|
|
46e. Other (specify: _____________________________ ) |
|
|
|
46f. Other (specify: _____________________________ ) |
|
|
|
46g. Other (specify: __ __________________________ ) |
|
|
|
Record the diagnostic measurements taken on THIS housing unit: (fill in all that were taken)
Diagnostic measurement |
Pre-weatherization |
Post weatherization |
House air leakage (blower door measurement): |
|
|
47a. Air leakage rate |
cfm |
cfm |
47b. House WRT outside pressure difference |
Pa |
Pa |
|
|
|
Duct leakage (pressure pan measurements): |
|
|
48a. Sum of pressure pan readings |
Pa |
Pa |
48b. Number of registers included in sum |
|
|
48c. House WRT outside pressure difference |
Pa |
Pa |
|
|
|
Duct leakage (duct blower measurements): |
|
|
49a. Total duct leakage rate |
cfm |
cfm |
49b. Duct leakage to the outside |
cfm |
cfm |
49c. Duct WRT outside pressure difference |
Pa |
Pa |
|
|
|
Steady-state efficiency (flue gas analysis): |
|
|
50a. Primary space-heating system |
% |
% |
50b. Secondary space-heating system |
% |
% |
50c. Hot water heater |
% |
% |
MEASURES INSTALLED
Identify the measures that were installed on THIS housing unit: (check all that apply)
Measure |
Installed by |
|
|
In-house crew |
Contractor |
Air sealing work: |
|
|
51a. General house caulking and weatherstripping (e.g., doors, windows) |
|
|
51b. House air sealing emphasizing bypasses (leaks identified by auditor and/or crew without using a blower door) |
|
|
51c. House air sealing emphasizing bypasses (leaks identified by auditor and/or crew with aid of a blower door) |
|
|
51d. Air distribution system (duct) sealing and repair |
|
|
51e. Other non-window air sealing work (specify: ______________ ) |
|
|
|
|
|
Insulation: |
|
|
52a. Attic insulation (installed where there was no existing insulation) |
|
|
52b. Attic insulation (added to existing insulation) |
|
|
52c. Wall insulation (normal density—two-hole gravity blow technique) |
|
|
52d. Wall insulation (high density—one-hole tube-fill technique) |
|
|
52e. Floor insulation |
|
|
52f. Rim or band joist insulation |
|
|
52g. Foundation wall insulation |
|
|
52h. Duct insulation |
|
|
52i. White roof coat |
|
|
52j. Skirting |
|
|
52k. Other insulation (specify: ______________________________ ) |
|
|
|
|
|
Windows: |
|
|
53a. New window (justified because cost effective) |
|
|
53b. New window (justified for reason other than cost effectiveness) |
|
|
53c. Window glazings |
|
|
53d. New window screen |
|
|
53e. Window lock replacement |
|
|
Measure |
Installed by |
|
|
In-house crew |
Contractor |
Windows (continued): |
|
|
53f. Window screen repair |
|
|
53g. Other window repair (e.g., sashes, frames) |
|
|
53h. Storm window |
|
|
53i. Window shading (e.g., awning, film, sun screen) |
|
|
53j. Other window treatments (specify: _______________________ ) |
|
|
|
|
|
Doors: |
|
|
54a. New door (justified because cost effective) |
|
|
54b. New door (justified for reason other than cost effectiveness) |
|
|
54c. Door lock (new or replacement) |
|
|
54d. Door or door framing repair |
|
|
54e. Storm door |
|
|
54f. Other door treatments (specify: __________________________ ) |
|
|
|
|
|
Space-heating systems: |
|
|
55a. New space-heating system (justified because cost effective) |
|
|
55b. New space-heating system (justified for reason other than cost effectiveness) |
|
|
55c. Space-heating system repair (e.g., controls, safety items, flues) |
|
|
55d. Space-heating system tune-up |
|
|
55e. Vent damper |
|
|
55f. Intermittent ignition device |
|
|
55g. Other space-heating system modification (specify: __________ ) |
|
|
|
|
|
Air-conditioning systems: |
|
|
56a. New air conditioner (justified because cost effective) |
|
|
56b. New air conditioner (justified for reason other than cost effectiveness) |
|
|
56c. Air conditioner repair |
|
|
Measure |
Installed by |
|
|
In-house crew |
Contractor |
Air-conditioning systems (continued): |
|
|
56d. Air conditioner recharge/tune-up |
|
|
56e. Ceiling or whole-house fans |
|
|
56f. Other air-conditioning system modification (specify: ________ ) |
|
|
|
|
|
Ventilation: |
|
|
57a. Exhaust fan in bathroom |
|
|
57b. Exhaust fan in kitchen |
|
|
57c. Whole-house ventilation system |
|
|
57d. Other ventilation system improvements (specify: ___________ ) |
|
|
|
|
|
HVAC accessories: |
|
|
58a. New programmable (setback) thermostat |
|
|
58b. New standard thermostat |
|
|
58c. Duct vents, grills, or registers |
|
|
58d. Standard air filter |
|
|
58e. High efficiency particulate arresting (HEPA) air filter |
|
|
58f. Other HVAC accessories (specify: _______________________ ) |
|
|
|
|
|
Water-heating system: |
|
|
59a. New water heater (justified because cost effective) |
|
|
59b. New water heater (justified for reason other than cost effectiveness) |
|
|
59c. Water-heating system repair |
|
|
59d. Water-heater tank insulation wrap |
|
|
59e. Pipe insulation |
|
|
59f. Low-flow showerhead |
|
|
59g. Faucet aerators |
|
|
59h. Water heater temperature reduction |
|
|
Measure |
Installed by |
|
Water-heating system (continued): |
In-house crew |
Contractor |
59i. Other water heating system measure (specify: ______________ ) |
|
|
|
|
|
Other baseloads: |
|
|
60a. Indoor lighting |
|
|
60b. Outdoor lighting |
|
|
60c. Refrigerator (justified because cost effective) |
|
|
60d. Refrigerator (justified for reason other than cost effectiveness) |
|
|
60e. Other baseload measure (specify: ________________________ ) |
|
|
|
|
|
Client education: |
|
|
61a. Literature (e.g., brochures, booklets, manuals) |
|
|
61b. Videos, DVDs, or compact disks (CDs) |
|
|
61c. Hardware kit and/or kit of weatherization materials |
|
|
61d. <5 minute total in-home education/discussion time |
|
|
61e. 5-14 minute total in-home education/discussion time |
|
|
61f. 15-29 minute total in-home education/discussion time |
|
|
61g. 30-60 minute total in-home education/discussion time |
|
|
61h. >1 hour total in-home education/discussion time |
|
|
61i. Classroom training |
|
|
61j. Other client education approach (specify: _______ ) |
|
|
|
|
|
Other health, safety, and repair: |
|
|
62a. Smoke alarm |
|
|
62b. CO monitor |
|
|
62c. Attic ventilation |
|
|
62d. Roof repair |
|
|
62e. Ceiling repair |
|
|
62f. Wall repair |
|
|
Measure |
Installed by |
|
Other health, safety, and repair (continued): |
In-house crew |
Contractor |
62g. Floor repair |
|
|
62h. Foundation repair |
|
|
62i. Ground vapor barrier |
|
|
62j. Gutter or downspout (installed or repaired) |
|
|
62k. Grading of lot |
|
|
62l. Plumbing repair |
|
|
62m. Sewer repair |
|
|
62n. Electrical repair |
|
|
62o. Stair repair |
|
|
62p. Install/repair non-skid material on stairs |
|
|
62q. Install/repair safety gate at stairs |
|
|
62r. Install/repair grab bar in bathroom |
|
|
62s. Install/repair non-skid material in bathtub |
|
|
62t. Install/repair metal chimney liner |
|
|
62u. Lead abatement |
|
|
62v. Asbestos abatement |
|
|
62w. Removal or safe storage of household poisons |
|
|
62x. Other H&S and repair items (specify: ____________________ ) |
|
|
63. If a new space-heating system was installed, indicate the primary fuel used to heat the unit during the winter after weatherization: (check only one)
Natural gas
Propane/LPG
Kerosene (#1 fuel oil)
Fuel oil (#2 fuel oil)
Electricity
Wood
Coal
Other (specify: ____________________)
Don’t know
Not applicable
64. If a new space-heating system was installed, indicate the type of primary space-heating system after weatherization: (check only one)
Central (ducted) warm-air furnace (forced-air or gravity, any fuel including electricity)
Heat pump
Built-in electric units (e.g., electric baseboards, ceiling heat)
Steam or hot water system (e.g., floor or baseboard radiators, convectors)
Floor, wall, or pipeless (ductless) furnace (e.g., floor or wall furnace)
Room/space heater (nonportable)
Portable space heater
Cooking stove
None
Don’t know
Not applicable
65. If a new space-heating system was installed and justified for reasons other than cost effectiveness, identify the reason it was replaced: (check all that apply)
Cost of repair/retrofit exceeded 50% of replacement cost
Existing heating system was not running
Existing heating system was old (e.g., at end of life, too old to be repaired/adjusted)
To switch fuel
To convert from a steam system to a hot water system
Heat exchanger was cracked
Boiler was leaking
Safety switches/controls were not operational and could not be repaired
To replace unvented space heater(s)
Existing heating system was not safe to run for other reason (specify: _____________)
Other (specifiy: ________________________________________________________)
66. Please identify any cost-effective energy-efficiency measures (not repair or health and safety measures) recommended by your energy audit procedures that you were unable to install in this housing unit because of insufficient funds: (check all that apply)
Air sealing
Duct sealing
Attic insulation
Wall insulation
Floor/foundation insulation
Duct insulation
New window(s)
Storm windows(s)
Door(s)
Storm door(s)
New space-heating system
Space-heating system tune-up
New air conditioner(s)
Air conditioner tune-up(s)
HVAC thermostat
New water heater
Water heater insulation wrap
Water flow devices (e.g., showerheads, faucet aerators)
Lighting
Refrigerator
Other: __________________________________________
None
67. If energy efficiency measures were checked in the previous question, provide a rough estimate of the cost for installing all the measures checked: $_______________
68. Please identify any repair or health and safety measures recommended by your audit procedures that you were unable to install in this housing unit because of insufficient funds: (check all that apply)
New window(s)
Window glazing(s)
Window screen(s)
Window lock(s)
Window repair
New door(s)
Door lock(s)
Door repair
New space-heating system
Space-heating system repair
New air conditioner(s)
Air conditioner repair
Ceiling or whole-house fan(s)
Exhaust fan(s) or ventilation system
New water heater
Water-heating system repair
Refrigerator
Smoke alarm
CO monitor
Attic ventilation
Roof, wall, floor, or foundation repair
Plumbing/sewer repair
Electrical repair
Other: __________________________________________
None
69. If repair or health and safety measures were checked in the previous question, provide a rough estimate of the cost for installing all the measures checked: $_______________
COSTS
Provide the costs associated with installing the measures in THIS housing unit from all funding sources. Do NOT include any program management costs such as those associated with intake and eligibility determination, audits and house assessments, final inspections, contractor or crew management, and program administration. Also, do NOT include installation-related overhead costs such as those associated with vehicles, equipment, and training.
|
In-House Crew |
Contractor |
Total |
70a. Material costs |
|
|
|
70b. Labor costs1 |
|
|
|
70c. Profit/overhead2 |
|
|
|
70d. Total3 |
|
|
|
1Crew-based labor costs should be based on the crew’s fully loaded hourly rate (rather than the crew’s take-home pay rate) which may include costs associated with medical and other insurance, workers compensation, vacations, and other benefits. These labor costs should include the crew’s time for traveling to and from the job site.
2If contractor profit and overhead are included in the contractor’s material and labor costs, then leave these cells blank.
3If the contractor costs are not split out by material and labor, then just enter the total costs. |
|||
Divide the total costs spent on this housing unit (cell in lower right corner of above table) into the following expenditure categories:
Expenditure category |
Costs1 |
71a. Cost effective energy-related measures (SIR > 1.0) |
|
71b. Incidental repairs |
|
71c. Health and safety, repairs, and other non-cost effective measures |
|
71d. Total |
|
171e. Labor and material |
|
Divide the total costs spent on this housing unit (cell in lower right corner of the two above tables) into the following funding sources:
Funding source |
Total funds |
72a. DOE funds |
|
72b. Non-DOE funds |
|
72c. Total |
|
Building Type Definitions:
Single-family detached house—House that provides living space for one family or household, is contained within walls that go from the basement (or the ground floor, if there is no basement) to the roof, and has no walls that are shared (or built in contact) with another household. A manufactured house assembled on site is a single-family detached housing unit, not a mobile home.
Single-family attached house—House that provides living space for one family or household, is contained within walls that go from the basement (or the ground floor, if there is no basement) to the roof, has at least one wall that is shared (or built in contact) with an adjacent household, and has an independent outside entrance. An attached house is not divided into more than one housing unit and does not have a household living above or below another one within the walls extending from the basement to the roof to separate any adjacent units. Examples include a house that is a side-by-side duplex, part of a townhouse building, and a row house.
Mobile home—Home that is built on a movable chassis, is moved to the site, and may be placed on a permanent or temporary foundation. If rooms are added to the structure, it is considered a mobile home if the added floor area is less than the mobile home’s original floor area; otherwise, it is a single-family detached house. A manufactured house assembled on site is a single-family detached house, not a mobile home.
Small multifamily—Building with two to four housing units (i.e., building that is divided into living quarters for two, three, or four families or households) in which one household lives above or beside another and does not meet the single-family attached house definition. Includes houses originally intended for occupancy by one family (or for some other use) that have since been converted to separate dwellings for two to four families. Typical arrangements in these types of living quarters are separate apartments downstairs and upstairs or one apartment on each of three or four floors.
Large multifamily—Building with five or more housing units (i.e., building that contains living quarters for five or more families or households) that does not meet the single-family attached house definition.
Shelter—Structure whose principal purpose is to house individuals on a temporary basis who may or may not be related to one another and who are not living in nursing homes, prisons, or similar institutional care facilities.
| File Type | application/msword |
| File Title | HOUSING UNIT INFORMATION SURVEY |
| Author | TERNESMP2 |
| Last Modified By | Preferred Customer |
| File Modified | 2010-09-18 |
| File Created | 2009-11-02 |