Weatherization Assistance Program Evaluation

Weatherization Assistance Program Evaluation

DF2 HOUSING UNIT INFORMATION DATA FORM for OMB - final 2nov09

Weatherization Assistance Program Evaluation

OMB: 1910-5151

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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.


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File Typeapplication/msword
File TitleHOUSING UNIT INFORMATION SURVEY
AuthorTERNESMP2
Last Modified ByPreferred Customer
File Modified2010-09-18
File Created2009-11-02

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