State Energy Program Evaluation

Non-residential On-Site Survey Form - Prescriptive Site ID #__________

Site ID #:

SiteID

Site Strata:

Survey Date:

Contact Information:

Building Name:			Utility:
Business Name:
Primary Contact Name:			Primary Contact Title:
Primary Phone:	Secondary Phone:			Email:
Alternative Contact Name:		Secondary Contact Title:
Alternative Contact Phone:
Building Address:
City: Zip:

Survey Tracking Information

Surveyor Name:	Travel Mileage:
Start Time:	Finish Time:	Total Time (mins): (Onsite, QC, Travel)

If the respondent is different than the contacts identified above, please identify name, title and contact information

Respondent Name:		Respondent Title:
Respondent Phone:		Respondent Email:

Circle any incidents as applicable:

1 None to report 7 Contact person unavailable or unaware of survey appointment

2 Complaint about rates 8 Customer expressed dissatisfaction with survey

3 Complaint about energy costs 9 Property damage occurred during on-site survey

4 Complaint about outages or power quality 10 Personal injury occurred during on-site survey

5 Complaint about technology reliability 11 Other (list) __________________________________________

6 Complaint about utility customer service

Month/Year of Participation	Month/Year of Work Completion
Number of Employees	Change in number of employees over the past 12 months?
Any significant changes to facility energy consumption over the past 12 months?	Y / N (if yes, please document the changes below)

Site & Survey Notes (Please note any changes to the household’s energy usage or occupancy over the past 12 months):

Background Information

Dwelling Information

Facility type
Year Built
Square footage of facility

Utility Information

	Electric	Natural Gas
Utility
Account Number
Meter Number

Installed Measures

	Measure Description	Quantity	Energy Savings	Units of Savings	Total Customer Cost
EE Measure 1
EE Measure 2
EE Measure 3
EE Measure 4
EE Measure 5
EE Measure 6
EE Measure 7
EE Measure 8

Interview & Introduction

Hello, my name is [NAME] and I work with KEMA Inc. I am working on behalf of [Sponsor] to conduct an independent assessment of energy-efficiency technologies installed under the &Program. I am here to meet with [FirstName1 LastName2] to discuss energy-using technologies in this facility. (Show letter, identification and business card.) During my visit I’d like to ask a few questions about your facility’s general characteristics and then would like walk through to note the number and type of lighting fixtures and visually inspect other relevant equipment including heating, cooling, water heating, refrigeration and motors equipment. The survey should take no more than 300 minutes to complete. Do you have any questions regarding my visit?

The U.S. Department of Energy (DOE) would like to inform each individual that the information requested here is being solicited under the statutory authority of Title III of the Energy Policy and Conservation Act of 1975, as amended, which authorizes DOE to administer the State Energy Program (SEP). This information is being sought as part of a national evaluation of SEP, the purpose of which is to reliably quantify Program accomplishments and help inform decisions on future operations. The sole use of the information collected will be for an analysis of national-level Program impacts. Disclosure of this information is voluntary and there will be no adverse effects associated with not providing all or any part of the requested information.

Building Plan Review

BP Identify the major functional spaces, or building areas, with distinct schedules or HVAC systems and determine the percentage of space distribution by building area where the project was installed. The total percentage of the floor area represented by these areas should represent the majority of the building (i.e., close to 100%). Use the Building Area Sketch Sheets to assist as necessary.

Area ID	Area Code	Area Description	% of Overall Building Area	% of Area Conditioned by
				Heating	Cooling	Uncond.	Refrigerated
A1
A2
A3
A4
A5
A6
A7
A8
A9
A10

AA Code	Activity Area Type Description	AA Code	HVAC Type Description	HVAC Code	HVAC Type Description
1	Auditorium/Gym	22	Guest Room (Hotel/Motel)	42	Religious Worship
2	Auto Repair Workshop	23	Kitchen/Break Room & Food Prep	43	Residential
3	Bank/Financial	24	Laboratory	44	Restrooms
4	Bar Cocktail Lounge	25	Laundry	45	Retail Sales / Showroom
5	Barber/Beauty Shop	26	Library	46	Smoking Lounge
6	Casino/Gaming	27	Loading Dock	47	Storage (Conditioned)
7	Classroom/Lecture	28	Lobby (Hotel)	48	Storage (Unconditioned)
8	Clean Room	29	Lobby (Main Entry and Assembly)	49	Storage (Refrigerated/Freezer), Walk-In
9	Computer Room/Data Processing	30	Lobby (Office ReceptionWaiting)	50	Storage (Refrigerated/Freezer), Building
10	Com/Ind Work (General High Bay)	31	Locker and Dressing Room	51	Surgery Rooms
11	Com/Ind Work (General Low Bay)	32	Mall Arcade and Atrium	52	Theater (Motion Picture)
12	Com/Ind Work (Precision)	33	Mechanical/Electrical Room	53	Theater (Performance)
13	Conference Room	34	Medical Offices and Exam Rooms	54	Unknown
14	Convention and Meeting Center	35	Office (Executive/Private)	55	Vacant (Conditioned)
15	Copy Room	36	Office (General)	56	Vacant (Unconditioned)
16	Corridor/Hallways	37	Office (Open Plan)	57	Vocational Areas
17	Courtrooms	38	Patient Rooms	98	Non Rebated Area
18	Dining Area	39	Patio Area	99	Other Unlisted Activity Types
19	Dry Cleaning	40	Pool/Spa Area
20	Exercise Centers/Gymnasium	41	Police/Fire Station	100	Outside / Outdoor Area
21	Exhibit Display Area / Museum

Description/Notes:

Building Area Sketch Sheet [Use additional sheets as necessary]

Identify orientation (N and E); Highlight logger locations

Building Operating Schedules

BP Define the building operating schedules for the building. Enter the operating hours for each schedule and then note the applicable building areas. (Enter 2400 for 24-hour operation, enter 0 for never open)

SCHD	Business Operating Hours								Area IDs
ID	Mon	Tue	Wed	Thu	Fri	Sat	Sun	Holidays	on this schedule
BH1	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10
BH2	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10
BH3	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10
BH4	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10
BH5	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10
BH6	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10
BH7	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10
BH8	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10
BH9	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10
BH10	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10

Description/Notes:

[IF BP1Cooling>0, else skip to BP4]

HVAC Operating Schedules

BP3: Define the HVAC Occupied and Unoccupied schedules for the building. Enter the occupied hours for each schedule and then note the applicable building areas. (Enter 2400 for 24-hour operation, enter 0 for never open)

HVAC	HVAC Operating Hours								Area IDs
ID	Mon	Tue	Wed	Thu	Fri	Sat	Sun	Holidays	on this schedule
H1	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	AA1 AA2 AA3 AA4 AA5 AA6 AA7 AA8 AA9 AA10
H2	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	AA1 AA2 AA3 BH4 AA5 AA6 AA7 AA8 AA9 AA10
H3	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	AA1 AA2 AA3 AA4 AA5 AA6 AA7 AA8 AA9 AA10
H4	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	AA1 AA2 AA3 AA4 AA5 AA6 AA7 AA8 AA9 AA10
H5	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	AA1 AA2 AA3 AA4 AA5 AA6 AA7 AA8 AA9 AA10
H6	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	AA1 AA2 AA3 AA4 AA5 AA6 AA7 AA8 AA9 AA10
H7	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	AA1 AA2 AA3 AA4 AA5 AA6 AA7 AA8 AA9 AA10
H8	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	AA1 AA2 AA3 AA4 AA5 AA6 AA7 AA8 AA9 AA10
H9	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	AA1 AA2 AA3 AA4 AA5 AA6 AA7 AA8 AA9 AA10
H10	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	AA1 AA2 AA3 AA4 AA5 AA6 AA7 AA8 AA9 AA10

[If BP1 Cooling or Heating >0, else skip to BP5]

Room Thermostat Setpoints

BP4. Enter the values for heating and cooling thermostat setpoints during normal (occupied) and setback (unoccupied) periods for each HVAC operation schedule

Interior Lighting Operating Hours

BP5: Define the interior lighting operating schedules for the building. Enter the interior lighting operating hours and then note the applicable building occupancy schedule. (Enter 2400 for 24-hour for lighting operation hours, enter 0 for never on).

SCHD	Interior Lighting Operating Hours								Area IDs
ID	Mon	Tue	Wed	Thu	Fri	Sat	Sun	Holidays	on this schedule
IL1	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	AA1 AA2 AA3 AA4 AA5 AA6 AA7 AA8 AA9 AA10
IL2	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	AA1 AA2 AA3 AA4 AA5 AA6 AA7 AA8 AA9 AA10
IL3	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	AA1 AA2 AA3 AA4 AA5 AA6 AA7 AA8 AA9 AA10
IL4	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	AA1 AA2 AA3 AA4 AA5 AA6 AA7 AA8 AA9 AA10
IL5	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	AA1 AA2 AA3 AA4 AA5 AA6 AA7 AA8 AA9 AA10
IL6	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	AA1 AA2 AA3 AA4 AA5 AA6 AA7 AA8 AA9 AA10
IL7	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	AA1 AA2 AA3 AA4 AA5 AA6 AA7 AA8 AA9 AA10
IL8	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	AA1 AA2 AA3 AA4 AA5 AA6 AA7 AA8 AA9 AA10
IL9	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	AA1 AA2 AA3 AA4 AA5 AA6 AA7 AA8 AA9 AA10
IL10	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	AA1 AA2 AA3 AA4 AA5 AA6 AA7 AA8 AA9 AA10

Exterior Lighting Operating Hours

BP6: Define the exterior lighting operating schedules for the building if on timer or manual switches. Enter the exterior lighting operating hours and then note the applicable building occupancy schedule. (Enter 2400 for 24-hour for lighting operation hours, enter 0 for never on).

SCHD	Exterior Lighting Operating Hours
ID	Mon	Tue	Wed	Thu	Fri	Sat	Sun	Holidays
EL1	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:
EL2	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:
EL3	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:
EL4	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:
EL5	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:	O: C:

BP7: How is the exterior lighting controlled? (check all that apply)

Manual Switches*		Daylight Sensors
Time Clock*		Other (explain)
Occupancy Sensors		Don’t Know

*If manual switches or time clock complete table <based on response to BP6>.

Description/Notes:

___________________________________________________________________________________________

___________________________________________________________________________________________

Building Characteristics

[If BP1 Heating >0, else skip to BC2] BC1. Space heating fuel type: E=Electricity G=Natural gas P=Propane EG=Electricity and gas N=Neither electricity or gas O=Other(specify) DK= Don’t know REF=Refused	E G P EG N O______________ DK REF
[If BC2=2 GO TO BC3, else skip to BC4] BC2. Age of building	_____________ Don’t know Refused
BC3. Age of building: Before 1950 1960’s 1970’s 1980’s 1990-1994 1995-1999 2000’s Don’t know Refused to answer	1 2 3 4 5 6 7 8 9
BC4. Primary business activity at the facility Office Retail (non-food) College/University School Grocery store Restaurant Health care (other than hospital) Hospital Hotel/Motel Warehouse Construction Community service/Religious/Municipality Industrial process/Manufacturing Condo association/Apt. management Greenhouse Laundry/Dry cleaner Other (specify)__________ Don’t know Refused	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17________________ 18 19
BC5. Number of part-time and full-time employees	_____________ Don’t know Refused

[If BP1 Cooling >0, else skip to H1]

Cooling Equipment –Verification of Installed Measures

Cooling Type <from tracking system>	C1. Cooling Type Installed*	C2. Qty Installed	C3. Capacity	C4. Efficiency	C5. Building Area ID	C6. Frequency of Use*	C7. Hrs of Operation Vary with Weather
	SS PS PTAC EC C IAC W O________________ DK REF		_____ tons ______kBtuh ______kW	_____ EER _____ SEER ______Btu/hr ______kW/ton ______ Other	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10	1 2 3 4 5	Y N DK REF
	SS PS PTAC EC C IAC W O________________ DK REF		_____ tons ______kBtuh ______kW	_____ EER _____ SEER ______Btu/hr ______kW/ton ______ Other	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10	1 2 3 4 5	Y N DK REF
	SS PS PTAC EC C IAC W O________________ DK REF		_____ tons ______kBtuh ______kW	_____ EER _____ SEER ______Btu/hr ______kW/ton ______ Other	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10	1 2 3 4 5	Y N DK REF
	SS PS PTAC EC C IAC W O________________ DK REF		_____ tons ______kBtuh ______kW	_____ EER _____ SEER ______Btu/hr ______kW/ton ______ Other	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10	1 2 3 4 5	Y N DK REF
	SS PS PTAC EC C IAC W O________________ DK REF		_____ tons ______kBtuh ______kW	_____ EER _____ SEER ______Btu/hr ______kW/ton ______ Other	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10	1 2 3 4 5	Y N DK REF
	SS PS PTAC EC C IAC W O________________ DK REF		_____ tons ______kBtuh ______kW	_____ EER _____ SEER ______Btu/hr ______kW/ton ______ Other	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10	1 2 3 4 5	Y N DK REF
	SS PS PTAC EC C IAC W O________________ DK REF		_____ tons ______kBtuh ______kW	_____ EER _____ SEER ______Btu/hr ______kW/ton ______ Other	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10	1 2 3 4 5	Y N DK REF
	SS PS PTAC EC C IAC W O________________ DK REF		_____ tons ______kBtuh ______kW	_____ EER _____ SEER ______Btu/hr ______kW/ton ______ Other	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10	1 2 3 4 5	Y N DK REF
	SS PS PTAC EC C IAC W O________________ DK REF		_____ tons ______kBtuh ______kW	_____ EER _____ SEER ______Btu/hr ______kW/ton ______ Other	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10	1 2 3 4 5	Y N DK REF

*KEY CODES

Cooling Type

SS=Split system

PS=Package system

PTAC=Package terminal AC or heat pump

EC=Evaporative cooler

C=Water chiller/cooling tower

IAC=Individual AC or heat pump

W=Window/Wall units

O = Other (describe)

DK = Don’t know

REF = Refused

Frequency of Use

1. All summer

2. Quite a bit

3. Only a few times when needed

4. Not at all

5. Don’t know

Notes:

Cooling Equipment – Discrepancy of Installed Measures (repeat set of questions for each type of equipment installed where verification identified discrepancies from tracking system and CATI data)

	Installed Equipment
CV1. Cooling Type SS=Split system PS=Package system PTAC=Package terminal AC or heat pump EC=Evaporative cooler C=Water chiller/cooling tower IAC=Individual AC or heat pump W=Window/Wall units O = Other (describe) DK = Don’t know REF = Refused	SS PS PTAC EC C IAC W O________________ DK REF
[IF C2 not equal to quantity in tracker, else skip to CV3] CV2. Reason quantity differed: Put into storage Installed at another facility Insufficient financial resources to complete Other (describe)_____________ Don’t know Refused	1 2 3 4 5___________________ 6 7
[IF C3 not equal to quantity in tracker, else skip to CR1] CV3. Reason capacity differed: Put into storage Installed at another facility Insufficient financial resources to complete Other (describe)_____________ Don’t know Refused	1 2 3 4 5___________________ 6 7
[IF C4 not equal to quantity in tracker, else skip to CR1] CV4. Reason capacity differed: Put into storage Installed at another facility Insufficient financial resources to complete Other (describe)_____________ Don’t know Refused	1 2 3 4 5___________________ 6 7

Notes:

Cooling Equipment – Replaced Equipment (repeat set of questions for each type of equipment replaced)

	Replaced Equipment
CR1. Cooling Type Replaced SS=Split system PS=Package system PTAC=Package terminal AC or heat pump EC=Evaporative cooler C=Water chiller/cooling tower IAC=Individual AC or heat pump W=Window/Wall units O = Other (describe) N=None DK= Don’t know REF= Refused	SS PS PTAC EC C IAC W O________________ N DK REF [If N, DK, REF skip to H1]
CR2. Quantity	________ Don’t know Refused
CR3. Capacity	_____ tons ______Btu/hr ______therm ______kW Don’t know Refused
CR4. Condition of replaced equipment G= Good F= Fair P=Poor I=Inoperable DK=Don’t know REF=Refused	G F P I DK REF
CR5. Efficiency	_____ EER _____ SEER ______Btu/hr ______kW/ton ______ Other
CR6. Estimated Age <5 years old 5-10 years old 11-20 years old >20 years old Don’t know Refused	1 2 3 4 5 6

Notes:

Heating Type <from tracking system>	H1. Heating Type Installed*	H2. Qty Installed	H3. Fuel Type	H4. Size	H5. Efficiency (AFUE)	H6. Building Area ID	H7. Frequency of Use*
	C P SH SS F D R O_________ DK REF		Electricity Natural gas Fuel oil LP gas Other_______	_______kW _____kBtuh ______HP Other______		A1 A2 A3 A4 A5 A6 A7 A8 A9 A10	1 2 3 4 5
	C P SH SS F D R O_________ DK REF		Electricity Natural gas Fuel oil LP gas Other_______	_______kW _____kBtuh ______HP Other______		A1 A2 A3 A4 A5 A6 A7 A8 A9 A10	1 2 3 4 5
	C P SH SS F D R O_________ DK REF		Electricity Natural gas Fuel oil LP gas Other_______	_______kW _____kBtuh ______HP Other______		A1 A2 A3 A4 A5 A6 A7 A8 A9 A10	1 2 3 4 5
	C P SH SS F D R O_________ DK REF		Electricity Natural gas Fuel oil LP gas Other_______	_______kW _____kBtuh ______HP Other______		A1 A2 A3 A4 A5 A6 A7 A8 A9 A10	1 2 3 4 5
	C P SH SS F D R O_________ DK REF		Electricity Natural gas Fuel oil LP gas Other_______	_______kW _____kBtuh ______HP Other______		A1 A2 A3 A4 A5 A6 A7 A8 A9 A10	1 2 3 4 5
	C P SH SS F D R O_________ DK REF		Electricity Natural gas Fuel oil LP gas Other_______	_______kW _____kBtuh ______HP Other______		A1 A2 A3 A4 A5 A6 A7 A8 A9 A10	1 2 3 4 5
	C P SH SS F D R O_________ DK REF		Electricity Natural gas Fuel oil LP gas Other_______	_______kW _____kBtuh ______HP Other______		A1 A2 A3 A4 A5 A6 A7 A8 A9 A10	1 2 3 4 5
	C P SH SS F D R O_________ DK REF		Electricity Natural gas Fuel oil LP gas Other_______	_______kW _____kBtuh ______HP Other______		A1 A2 A3 A4 A5 A6 A7 A8 A9 A10	1 2 3 4 5
	C P SH SS F D R O_________ DK REF		Electricity Natural gas Fuel oil LP gas Other_______	_______kW _____kBtuh ______HP Other______		A1 A2 A3 A4 A5 A6 A7 A8 A9 A10	1 2 3 4 5

*KEY CODES

Heating Types

C=Central Boiler

P=Package Heating Units

SH=Individual Space Heater/Portable Room Heater/Strip Heating

SS=Split-system Heat Pumps

F=Central Furnaces

D=District Steam or Hot Water

R=Radiant Heaters

O=Other (specify)____________

DK=Don’t know

REF=Refused

Notes:

Heating Equipment –Installed Measures Discrepancies (repeat set of questions for each type of equipment installed where verification identified discrepancies from tracking system and CATI data)

	Installed Equipment
HV1. Heating Type Installed C=Central boilers P=Package heating units SH=Individual space heater/portable room heater/strip heating SS=Split system heat pumps F=Central furnaces D=District steam or hot water R=Radiant heaters O=Other (specify)______ DK=Don’t know REF=Refused	C P SH SS F D R O_____________ DK REF
[Ask If quantity not equal to quantity in tracker, else skip to HV3] HV2. Reason quantity differed: Put into storage Installed at another facility Insufficient financial resources to complete Other (describe)_____________ Don’t know Refused	1 2 3 4 5___________________ 6 7
[Ask If capacity not equal to quantity in tracker, else skip to HR1] HV3. Reason capacity differed: Put into storage Installed at another facility Insufficient financial resources to complete Other (describe)_____________ Don’t know Refused	1 2 3 4 5___________________ 6 7

Notes:

Heating Equipment – Replaced Equipment (repeat set of questions for each type of equipment replaced)

	Replaced Equipment
HR1. Heating Type Replaced C=Central boilers P=Package heating units SH=Individual space heater/portable room heater/strip heating SS=Split system heat pumps F=Central furnaces D=District steam or hot water R=Radiant heaters O=Other (specify)______ N = None DK=Don’t know REF=Refused	C P SH SS F D R O_____________ N DK REF [If N, DK, REF, skip to CDV1]
HR2. Quantity	________ Don’t know Refused
HR3. Capacity	_____ tons ______Btu/hr ______therm ______kW Don’t know Refused
HR4. Condition of replaced equipment G= Good F= Fair P=Poor I=Inoperable DK=Don’t know REF=Refused	G F P I DK REF
HR5. Efficiency	_____ EER _____ SEER ______Btu/hr ______kW/ton ______ Other
HR 6. Estimated Age <5 years old 5-10 years old 11-20 years old >20 years old Don’t know Refused	1 2 3 4 5 6

Notes:

[If BP1 Heating or Cooling >0, else skip to RV1]

Heating/Cooling Controls and VSD Equipment – Installed

(repeat set of questions for each type of equipment installed under the program)

	Installed Equipment
CDV1. Controls Type Installed ASD=Adjustable speed drives or variable speed drives EMS=Energy management system CMT=HVAC controls – manual thermostat CBT=HVAC controls – bypass timer CTC=HVAC controls – time clock CPT=HVAC controls – programmable thermostat SV=CO2 sensor/demand control ventilation E=EconomizersO=Other (specify)______ N = None DK=Don’t know REF=Refused	ASD EMS CMT CBT CTC CPT SV E O_____________ N DK REF [If N, DK, REF, skip to R1]
CDV2. Quantity	________ Don’t know Refused
CDV3. Percentage of total enclosed floor space in the facility the control serves?	________ Don’t know Refused
[Ask If CDV2 not equal to quantity in tracker, else skip to CDR1] CDV4. Reason quantity differed: Put into storage Installed at another facility Insufficient financial resources to complete Other (describe)_____________ Don’t know Refused	1 2 3 4 5___________________ 6 7

Notes:

Heating/Cooling Controls and VSD Equipment – Replaced

	Replaced Equipment
CDR1. Controls Type Replaced ASD=Adjustable speed drives EMS=Energy management system CMT=HVAC controls – manual thermostat CBT=HVAC controls – bypass timer CTC=HVAC controls – time clock CPT=HVAC controls – programmable thermostat SV=CO2 sensor/demand control ventilation E=Economizers O=Other (specify)______ N=None DK=Don’t know REF=Refused	ASD EMS CMT CBT CTC CPT SV E O_____________ N DK REF [If N, DK, REF, skip to R1]
CDR2. Quantity	________ Don’t know Refused
CDR3. Condition of replaced equipment G= Good F= Fair P=Poor I=Inoperable DK=Don’t know REF=Refused	G F P I DK REF
CDR4. Estimated Age <5 years old 5-10 years old 11-20 years old >20 years old Don’t know Refused	1 2 3 4 5 6

Notes:

Refrigeration Equipment – Installed

(repeat set of questions for each type of equipment installed under the program)[If BP1 Refrigeration >0, else skip to M1]

	Installed Equipment
RV1. Refrigeration Measure RR=Residential sized refrigerator RF=Residential sized freezer LR=Large standard refrigerator (>30 cf) HC=Self contained – coffin/horizontal case VC=Self contained – vertical case (multi shelf) SDO=Single deck display cases - open single deck SDD=Single deck display cases – glass door cases MDO=Multi deck display cases – open single deck MDD=Multi deck display cases – glass door cases WF=Walk-in freezers O=Other (specify)______ DK=Don’t know REF=Refused	RR RF LR HC VC SDO SDD MDO MDD WF O_____________ DK REF
RV2. Quantity	________ Don’t know Refused
[Ask If RV2 not equal to quantity in tracker, else skip to RV4] RV3. Reason quantity differed: Put into storage Installed at another facility Insufficient financial resources to complete Other (describe)_____________ Don’t know Refused	1 2 3 4 5___________________ 6 7
RV4. How many were used to REPLACE existing units?	________ Don’t know Refused
RV5. Total size of the units installed to replace existing units	________ Don’t know Refused
RV6. How many were used to INCREASE refrigeration capacity?	________ Don’t know Refused
RV7. Total size of the units installed to increase refrigeration capacity	________ Don’t know Refused
RV8. Number of hours the unit is left open	________ Don’t know Refused
RV9. When the unit is closed, number of times it is opened per hour	________ Don’t know Refused

Notes:

	Replaced Equipment
[Ask If RV4>0, else skip to M1] RR1. Amount of refrigeration equipment removed compared to the amount of capacity installed: Same More Less Don’t know Refused	1 2 3 4 5
[Ask If RR1 =2, else skip to RR3] RR2. How much LESS capacity was installed?	________ Don’t know Refused
[Ask If RR1 =3, else skip to RR4] RR3. How much MORE capacity was installed?	________ Don’t know Refused
RR4. What year was the old equipment removed? 2008 2009 2010 2011 Don’t know Refused	1 2 3 4 5 6
RR5. Condition of replaced equipment G= Good F= Fair P=Poor I=Inoperable DK=Don’t know REF=Refused	G F P I DK REF
RR6. Estimated age of removed equipment <5 years old 5-10 years old 11-20 years old >20 years old Don’t know Refused	1 2 3 4 5 6
RR7. Percentage of removed capacity disposed of by the following methods: Never removed equipment Sent to landfill Moved to another location in the company Sold or given to another company or residence for use Recycled or sold for scrap Don’t know Refused	__________ __________ ___________ ___________ ___________ ___________ ___________

Notes:

Motors – Verification of Installed Measures

Motor Size (HP)	M1: Qty Purchased <from tracking>	M2: Qty Installed	M3: Qty Premium Efficiency	[If M2 not equal to M1] M4: Reason for Qty Discrepancy*	M5: Equipment Type Driven by Motor (multiple responses)*	M6: Qty Replaced	M7: Qty of Existing Motors Rewound
1-5
6-20
21-50
51-100
101-200
201-500

*KEY CODES

Reason for quantity discrepancy:

1. Put into storage

2. Installed at another facility

3. Insufficient financial resources to complete

4. Other (describe)_____________

5. Don’t know

6. Refused

Motor Applications:

1. HVAC equipment (describe in notes section the type of equipment: condenser fans, exhaust fans, etc.)

2. Pump (describe in notes section type of equipment: hot water pumps, chilled water primary pump, chilled water secondary pump, hot water secondary or primary pump, condenser pumps, etc.)

3. Fan

4. Air compressor

5. Conveyor belt or other materials handling

6. Production process machinery

7. Other(describe)______________

8. Don’t know

9. Refused

Motors – Hours of Operation for Non-HVAC Installed Motors (repeat for each multiple response to M5)

	Non-HVAC Installed Motors
M8. Number of hours per day the equipment typically operates	________ Don’t know Refused
M9. Number of days per week the equipment typically operates	________ Don’t know Refused
M10. Are there months during the year that differ significantly from the responses to M8 and M9?	Yes No Don’t know Refused
[Ask If M10 = Yes, else skip to L1] M11. Number of hours per day the equipment operates during the periods with different operating schedules	________ Don’t know Refused
M12. Number of days per week does the equipment operates during the periods with different operating schedules	________ Don’t know Refused
M12. Number of months the equipment operates on the different operating schedules	________ Don’t know Refused

Notes:

Lighting Equipment and Controls – Verification of Installed Measures

Measure Type <from tracking system>	L1. Qty Installed	L2. Wattage of Installed Measure	L3. Operational	L4. Building Area ID	L5. Square Feet Served by Measure
			Y N	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10	________ Don’t know Refused
			Y N	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10	________ Don’t know Refused
			Y N	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10	________ Don’t know Refused
			Y N	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10	________ Don’t know Refused
			Y N	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10	________ Don’t know Refused
			Y N	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10	________ Don’t know Refused
			Y N	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10	________ Don’t know Refused
			Y N	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10	________ Don’t know Refused
			Y N	A1 A2 A3 A4 A5 A6 A7 A8 A9 A10	________ Don’t know Refused

Lighting Control Measures

Control Measure Type <from tracking system>	LC1. Wattage Controlled	LC2. Hours/day before Control	LC3. % Reduction in Operating Hours
			________ Don’t know Refused
			________ Don’t know Refused
			________ Don’t know Refused
			________ Don’t know Refused
			________ Don’t know Refused
			________ Don’t know Refused
			________ Don’t know Refused
			________ Don’t know Refused
			________ Don’t know Refused

Lighting – Installed Measures Discrepancies (repeat set of questions for each type of equipment installed where verification identified discrepancies from tracking system and CATI data)

	Installed Equipment
[Ask If L1 differs from quantity in trackers, else LV2] LV1. Reason quantity differed: No idea Put into storage Installed at another facility Insufficient financial resources to complete Other (describe)_____________ Don’t know Refused	1 2 3 4 5___________________ 6 7
[Ask If L2 differs from quantity in trackers, else LR1] LV2. Reason wattage differed: Put into storage Installed at another facility Insufficient financial resources to complete Other (describe)_____________ Don’t know Refused	1 2 3 4 5___________________ 6 7

Notes:

Lighting – Replaced Equipment (repeat set of questions for each type of equipment replaced)

	Replaced Equipment
LR1: Type of lighting fixtures replaced*	[If N, DK, REF, skip to O1, else continue to LR2]
LR2. Did you remove the same number of old fixtures as installed? Same More Less Don’t know Refused	1 2 3 4 5
[If LR2=2, else skip to LR4] LR3. How fewer fixtures were installed?	________ Don’t know Refused
[If LR2=2, else skip to LR8] LR4. How many more fixtures installed?	________ Don’t know Refused
LR 5. Estimated age of removed equipment	________ Don’t know Refused

*KEY CODES

N= Did not replace anything

HT8= High performance T8 – 1” diameter bulbs

T8= T8 fluorescent fixtures – 1” diameter bulbs

T10= T10 fluorescent fixtures

T12= T12 fixtures – 1.5” diameter bulbs

HID= High density discharge fixtures, compact

CFS=Compact fluorescent – screw-in modular

CFH= Compact fluorescent – hardwire

I=Incandescent

EXCF=Exit signs – compact fluorescent

EXL=Exit signs – LED

H=Halogen

EB=Electronic ballast

DK = Don’t know

REF= Refused

MB=Magnetic ballast

FT=Fat/thick tubes

ST=Skinny/thin tubes

T5=T5 fixtures – 5/8” diameter

HPS=High pressure sodium

MH=Metal halide

MV=Mercury vapor

OTH=Other (specify)

DK=Don’t know

REF=Refused

Other Measure Verification

O1. Type of equipment	­­­____________________
O2. Quantity installed through the program	Number _________ Don’t know Refused
O3. Facility’s square footage served by this equipment	_________ Don’t know Refused
O4. Type of equipment that was replaced		­­­____________________
O5. Condition of replaced equipment G= Good F= Fair P=Poor I=Inoperable DK=Don’t know REF=Refused		G F P I DK REF
O6. Estimated Age <5 years old 5-10 years old 11-20 years old >20 years old Don’t know Refused		1 2 3 4 5 6
O7. Did you remove the same amount of equipment as installed? Same More Less Don’t know Refused		1 2 3 4 5

Notes:

SEP – Non-residential On-site M&V - Prescriptive Page 6, Sheet _____ of _____