Weatherization Assistance Program ARRA-Period Evaluation

DF4: Electric & Natural Gas Bills Information from Agencies Data Form

Utility Information Survey Part A	DF4a
OMB control number XXXX-XXXX; Expiration Date: MM/DD/YYYY
Introduction Thank you for your prompt response to this data request which is part of the ARRA-period evaluation of the Weatherization Assistance Program. Evaluation results will provide essential feedback to the weatherization community and inform policymakers about the program's effects on clients' energy consumption, cost savings, and non-energy benefits. This data form collects detailed information about homes weatherized by your agency in Program Years 2009 and 2010. The data you supply will be used to characterize the program and collect utility billing histories pre- and post-weatherization to better understand energy savings attributable to the Weatherization Assistance Program during the ARRA period. All of the information obtained from this survey and from utilities 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.
Instructions Part A of the DF4 survey requests a list of the housing units and large multifamily buildings your agency weatherized in PY 2010* and PY 2011†. The evaluation team will use the information provided in Part A to randomly select a sample of housing units and large multifamily buildings weatherized by your agency. After the sample is determined, you will be asked to complete Part B by providing detailed information about sampled units: housing type, primary heating fuel, occupant demographics and utility account information. *For the purposes of this survey, Program Year 2010 is the WAP/ARRA funding year that includes the heating season spanning late 2010/early 2011. †For the purposes of this survey, Program Year 2011 is the WAP/ARRA funding year that includes the heating season spanning late 2011/early 2012.
Public reporting burden for this collection of information is estimated to average 10 hours 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 (_______), 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 (_____), Washington, DC 20503.

Utility Information Survey Part A	DF4a
OMB control number

To be completed by the evaluation team:

Agency name
Agency ID
Contact name

Section 1: List of weatherized housing units

Please list all housing units that were weatherized during PY2010 and PY2011 using funds from DOE¹. Include all housing types. Do not include wait-listed or in-progress jobs.

Program year	Housing unit unique ID (e.g. job number)	Building type SFA – Singe family attached SFD – Single family detached SFU – Single family unknown attached/detached MH – Mobile home SH – Shelter SMF – Small multifamily (2-4 units) LMF – Large multifamily (5+ units)s	Primary heating fuel EL – electricity NG – natural gas LP – propane FO – fuel oil WO – wood OT – other

Utility Information Survey Part A	DF4a
OMB control number XXXX-XXXX

Section 2: List of large multifamily buildings

[Section 2 will only appear if the respondent selects “LMF” for at least one housing unit in Section 1.]

Please list all large multifamily buildings (5+ housing units) that were weatherized during PY20010 and PY2011 using DOE funds in which improvements were made to the building shell, common areas, central HVAC or domestic hot water systems. Do NOT include buildings where individual tenant units were weatherized but no improvements were made to the building shell, common areas, central HVAC or domestic hot water systems. Do not include wait-listed or in-progress jobs.

Program year	Building unique ID (building-level identification number)	Primary heating fuel EL – electricity NG – natural gas LP – propane FO – fuel oil WO – wood OT – other

Utility Information Survey Part B	DF4b
OMB control number XXXX-XXXX
Introduction Thank you for your prompt response to this data request which is part of the ARRA-period evaluation of the Weatherization Assistance Program. Evaluation results will provide essential feedback to the weatherization community and inform policymakers about the program's effects on clients' energy consumption, cost savings, and non-energy benefits. This data form collects detailed information about homes weatherized by your agency in Program Years 2010 and 2011. The data you supply will be used to characterize the program and collect utility billing histories pre- and post-weatherization to better understand energy savings attributable to the Weatherization Assistance Program during the ARRA period. All of the information obtained from this survey and from utilities 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.
Instructions In Part B of the DF4 survey we request detailed information about a randomly-selected sample of housing units that your agency weatherized in PY 2010* and PY 2011†. Information requested in Part B includes housing type, primary heating fuel, occupant demographics and utility account information. *For the purposes of this survey, Program Year 2010 is the WAP/ARRA funding year that includes the heating season spanning late 2010/early 2011. †For the purposes of this survey, Program Year 2011 is the WAP/ARRA funding year that includes the heating season spanning late 2011/early 2012.
Public reporting burden for this collection of information is estimated to average 20 hours 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 (_______), 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 (_____), Washington, DC 20503.

Utility Information Survey Part B	DF4b
OMB control number XXXX-XXXX

To be completed by the evaluation team:

Agency name
Agency ID
Contact name

Section 1: Information about sampled housing units

Unique ID for housing unit (e.g. job number)							[Pre-populated from Part A data]
Head of household name (first & last)
Street address			Apt #		City				Zip code
Occupant demographics
Number of household occupants	Number of elderly (60 or older)	Number of disabled				Number of Native American		Number of children (as defined by state)
Household annual income
Does the housing unit meet your state's definition of being a high residential energy user? Yes No Don’t know				Does the housing unit meet your state's definition of having a high energy burden? Yes No Don’t know
Ownership Owner (paid in full or mortgaged) Renter Occupied without payment Don’t know				Race/ethnicity of head of household American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White Hispanic or Latino Don’t know
Is household headed by a single parent? Yes No Don’t know

Utility account information For units in large multifamily buildings, only list accounts that are paid by the tenant. Do not list utility accounts that serve multiple dwelling units, common areas, or the entire building. Building-level utility account information will be requested in Section 2.
Housing type		[Pre-populated from Part A data]
Primary heating fuel		[Pre-populated from Part A data]
Electric utility name		Natural gas utility name2
Weatherization start date		Weatherization end date
Electric utility account number		Natural gas utility account number3
I certify that the agency has a signed utility billing data release form on file for this client.			Check to certify

Section 2: Information about sampled large multifamily buildings (5+ units)

[Agencies will see a series of screens, each one requesting the following information about a sampled large multifamily building.]

Building unique ID	[Pre-populate from Section 1]
Number of housing units in building			Number of weatherized housing units
Street Address			City	Zip code
Does this building have one or more electric or natural gas utility meters that provide service to multiple dwelling units or common areas in the building? For example, answer “yes” if the building has a natural gas meter that provides heat for the whole building or an electric meter that serves hallways and common areas.				Yes No Don’t know
Utility account information for building-level meters				Check if this meter serves multiple buildings
Electric account number 1
Electric account number 2
Electric account number 3
Electric account number 4
Electric account number 5
Natural gas account number 1
Natural gas account number 2
Natural gas account number 3
Natural gas account number 4
Natural gas account number 5
Do you have signed utility billing data release forms on file for any of these master-metered accounts?				Yes No Don’t know

1 Include all units that meet the definition of a “DOE Unit:” A DOE unit is a dwelling on which a DOE-approved energy audit or priority list has been applied and weatherization work has been completed. As funds allow, the DOE measures installed on this unit have a Savings-to-Investment Ratio (SIR) of 1.0 or greater, but also may include any necessary energy-related health and safety measures. The use of DOE funds on this unit may include, but are not limited to auditing, testing, measure installation, inspection, or use of DOE equipment and/or vehicles, or if DOE provides the training and/or administrative funds. Therefore, a dwelling unit that meets both the definition of a DOE weatherized unit and has DOE funds used directly on it must be counted as a DOE unit.

2 If primary heating fuel is not natural gas provided by a utility, please leave this cell blank. Do NOT list propane or fuel oil providers.

3 If primary heating fuel is not natural gas provided by a utility, please leave this cell blank. Do NOT list propane or fuel oil account numbers.