Weatherization Assistance Program Evaluation

OMB Control Number: 1910-5151

DF9: Contact Information from Agencies for Occupant Survey

This information is being collected to choose a sample of homes that are expected to receive weatherization in order to administer a survey to the occupants.  The information will be used to build a sampling frame to use to randomly select homes for this survey.

Public reporting burden for this collection of information is estimated to average one hour per response, 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.

Introduction: As part of the national evaluation of the Weatherization Assistance Program, occupants of housing units weatherized in Program Year 2010 will be surveyed before and after weatherization to obtain information on their health and demographics, determine their energy consumption behavior and knowledge, evaluate non-energy benefits, and establish their satisfaction with the Program. In addition, occupants of households that have received (or will receive) assistance from the Low-Income Home Energy Assistance Program (LIHEAP) but whose houses have not been (or will not be) weatherized will be surveyed to serve as a control group for the occupant survey.

We would like to survey several such occupants served by your agency. In order for us to randomly select several weatherized households, please provide us with the names and contact information for clients currently in the queue (i.e., in line) for receiving audits using the first attached form. Similarly, please use the second attached form to provide us with the names and contact information for clients your agency has provided, or will provide, LIHEAP assistance in Program Year 2010 so we can select several control households (provide a maximum of 20 names). [NOTE: If weatherization services and LIHEAP assistance are provided by two separate organizations, then similar instructions and forms will be used that only request information on weatherization clients or LIHEAP recipients.]

The information that you provide and that we obtain from the occupants will be protected and will remain confidential. When results of the survey are reported, information collected from the occupants will not be associated with their names in any way. In order to maintain the integrity of the survey, we will not be able to tell you which clients have been selected for the survey. We will be paying the occupants a small incentive to participate in the survey, so an undo burden will not be placed on your clients.

Clients in Queue for Audits

Agency name: _______________________________

State: ______________________________________

Date: ______________________________________

Please provide the following information for clients currently in the queue to receive audits by your agency.

	Name	Address	City	State	Zip Code	Phone Number	Expected Audit Date
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.

Clients That Have or Will Receive LIHEAP Assistance in WAP Program Year 2010

Agency name: _______________________________

State: ______________________________________

Date: ______________________________________

Please provide the following information for clients to whom your agency has provided, or will provide, LIHEAP assistance in WAP Program Year 2010:

	Identification Number	Name	Address	City	State	Zip Code	Phone Number
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.

3