Weatherization Assistance Program ARRA-Period Evaluation

OMB Control Number: XXXX-XXXX-

Expiration Date: MM/DD/YYYY

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.  All of the information obtained via this data form will be protected and will remain confidential. 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.

Introduction: As part of the national evaluation of the Weatherization Innovative Pilot Program, occupants of housing units weatherized using WIPP funds will be surveyed after weatherization to obtain information and establish their satisfaction with the weatherization services provided.

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 that received WIPP-related weatherization services provided during your grant period using attached form.

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 no undue burden will not be placed on your clients.

Clients Received Weatherization

Grantee name: _______________________________

State: ______________________________________

Date: ______________________________________

Please provide the following information for clients that received WIPP-related weatherization services from your organization. Please add additional rows as necessary. A data file can also be provided and transferred using our secure server.

Name	Address	City	State	Zip Code	Phone Number	Wx Completion Date

2