State Energy Program Evaluation

State Energy Program Evaluation

OS-2 Non-Residential v.082112

State Energy Program Evaluation

OMB: 1910-5170

Document [docx]
Download: docx | pdf

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


  1. _____________

  2. Don’t know

  3. Refused

BC3. Age of building:

  1. Before 1950

  2. 1960’s

  3. 1970’s

  4. 1980’s

  5. 1990-1994

  6. 1995-1999

  7. 2000’s

  8. Don’t know

  9. Refused to answer

1 2 3 4 5 6 7


8 9

BC4. Primary business activity at the facility


  1. Office

  2. Retail (non-food)

  3. College/University

  4. School

  5. Grocery store

  6. Restaurant

  7. Health care (other than hospital)

  8. Hospital

  9. Hotel/Motel

  10. Warehouse

  11. Construction

  12. Community service/Religious/Municipality

  13. Industrial process/Manufacturing

  14. Condo association/Apt. management

  15. Greenhouse

  16. Laundry/Dry cleaner

  17. Other (specify)__________

  18. Don’t know

  19. 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

  1. _____________

  2. Don’t know

  3. 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:


  1. Put into storage

  2. Installed at another facility

  3. Insufficient financial resources to complete

  4. Other (describe)_____________

  5. Don’t know

  6. Refused



1 2 3 4


5___________________


6 7

[IF C3 not equal to quantity in tracker, else skip to CR1]

CV3. Reason capacity differed:


  1. Put into storage

  2. Installed at another facility

  3. Insufficient financial resources to complete

  4. Other (describe)_____________

  5. Don’t know

  6. Refused



1 2 3 4


5___________________


6 7

[IF C4 not equal to quantity in tracker, else skip to CR1]

CV4. Reason capacity differed:


  1. Put into storage

  2. Installed at another facility

  3. Insufficient financial resources to complete

  4. Other (describe)_____________

  5. Don’t know

  6. 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

  1. ________

  2. Don’t know

  3. Refused

CR3. Capacity


  1. _____ tons

  2. ______Btu/hr

  3. ______therm

  4. ______kW

  5. Don’t know

  6. 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

  1. <5 years old

  2. 5-10 years old

  3. 11-20 years old

  4. >20 years old

  5. Don’t know

  6. 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


  1. Electricity

  2. Natural gas

  3. Fuel oil

  4. LP gas

  5. Other_______

  1. _______kW

  2. _____kBtuh

  3. ______HP

  4. 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


  1. Electricity

  2. Natural gas

  3. Fuel oil

  4. LP gas

  5. Other_______

  1. _______kW

  2. _____kBtuh

  3. ______HP

  4. 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


  1. Electricity

  2. Natural gas

  3. Fuel oil

  4. LP gas

  5. Other_______

  1. _______kW

  2. _____kBtuh

  3. ______HP

  4. 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


  1. Electricity

  2. Natural gas

  3. Fuel oil

  4. LP gas

  5. Other_______

  1. _______kW

  2. _____kBtuh

  3. ______HP

  4. 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


  1. Electricity

  2. Natural gas

  3. Fuel oil

  4. LP gas

  5. Other_______

  1. _______kW

  2. _____kBtuh

  3. ______HP

  4. 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


  1. Electricity

  2. Natural gas

  3. Fuel oil

  4. LP gas

  5. Other_______

  1. _______kW

  2. _____kBtuh

  3. ______HP

  4. 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


  1. Electricity

  2. Natural gas

  3. Fuel oil

  4. LP gas

  5. Other_______

  1. _______kW

  2. _____kBtuh

  3. ______HP

  4. 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


  1. Electricity

  2. Natural gas

  3. Fuel oil

  4. LP gas

  5. Other_______

  1. _______kW

  2. _____kBtuh

  3. ______HP

  4. 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


  1. Electricity

  2. Natural gas

  3. Fuel oil

  4. LP gas

  5. Other_______

  1. _______kW

  2. _____kBtuh

  3. ______HP

  4. 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:


  1. Put into storage

  2. Installed at another facility

  3. Insufficient financial resources to complete

  4. Other (describe)_____________

  5. Don’t know

  6. 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:


  1. Put into storage

  2. Installed at another facility

  3. Insufficient financial resources to complete

  4. Other (describe)_____________

  5. Don’t know

  6. 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

  1. ________

  2. Don’t know

  3. Refused

HR3. Capacity


  1. _____ tons

  2. ______Btu/hr

  3. ______therm

  4. ______kW

  5. Don’t know

  6. 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

  1. <5 years old

  2. 5-10 years old

  3. 11-20 years old

  4. >20 years old

  5. Don’t know

  6. 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

  1. ________

  2. Don’t know

  3. Refused

CDV3. Percentage of total enclosed floor space in the facility the control serves?

  1. ________

  2. Don’t know

  3. Refused

[Ask If CDV2 not equal to quantity in tracker, else skip to CDR1]


CDV4. Reason quantity differed:


  1. Put into storage

  2. Installed at another facility

  3. Insufficient financial resources to complete

  4. Other (describe)_____________

  5. Don’t know

  6. 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

  1. ________

  2. Don’t know

  3. 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

  1. <5 years old

  2. 5-10 years old

  3. 11-20 years old

  4. >20 years old

  5. Don’t know

  6. 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

  1. ________

  2. Don’t know

  3. Refused

[Ask If RV2 not equal to quantity in tracker, else skip to RV4]


RV3. Reason quantity differed:


  1. Put into storage

  2. Installed at another facility

  3. Insufficient financial resources to complete

  4. Other (describe)_____________

  5. Don’t know

  6. Refused



1 2 3 4


5___________________


6 7

RV4. How many were used to REPLACE existing units?

  1. ________

  2. Don’t know

  3. Refused

RV5. Total size of the units installed to replace existing units

  1. ________

  2. Don’t know

  3. Refused

RV6. How many were used to INCREASE refrigeration capacity?

  1. ________

  2. Don’t know

  3. Refused

RV7. Total size of the units installed to increase refrigeration capacity

  1. ________

  2. Don’t know

  3. Refused

RV8. Number of hours the unit is left open

  1. ________

  2. Don’t know

  3. Refused

RV9. When the unit is closed, number of times it is opened per hour

  1. ________

  2. Don’t know

  3. 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:


  1. Same

  2. More

  3. Less

  4. Don’t know

  5. Refused




1 2 3 4 5

[Ask If RR1 =2, else skip to RR3]


RR2. How much LESS capacity was installed?

  1. ________

  2. Don’t know

  3. Refused

[Ask If RR1 =3, else skip to RR4]

RR3. How much MORE capacity was installed?

  1. ________

  2. Don’t know

  3. Refused

RR4. What year was the old equipment removed?


  1. 2008

  2. 2009

  3. 2010

  4. 2011

  5. Don’t know

  6. 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

  1. <5 years old

  2. 5-10 years old

  3. 11-20 years old

  4. >20 years old

  5. Don’t know

  6. Refused


1 2 3 4 5 6

RR7. Percentage of removed capacity disposed of by the following methods:


  1. Never removed equipment

  2. Sent to landfill

  3. Moved to another location in the company

  4. Sold or given to another company or residence for use

  5. Recycled or sold for scrap

  6. Don’t know

  7. Refused


  1. __________

  2. __________

  3. ___________

  4. ___________

  5. ___________

  6. ___________

  7. ___________









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

  1. ________

  2. Don’t know

  3. Refused

M9. Number of days per week the equipment typically operates

  1. ________

  2. Don’t know

  3. Refused

M10. Are there months during the year that differ significantly from the responses to M8 and M9?

  1. Yes

  2. No

  3. Don’t know

  4. 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



  1. ________

  2. Don’t know

  3. Refused

M12. Number of days per week does the equipment operates during the periods with different operating schedules



  1. ________

  2. Don’t know

  3. Refused

M12. Number of months the equipment operates on the different operating schedules



  1. ________

  2. Don’t know

  3. 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

  1. ________

  2. Don’t know

  3. Refused




Y N

A1 A2 A3 A4 A5 A6 A7 A8 A9 A10

  1. ________

  2. Don’t know

  3. Refused




Y N

A1 A2 A3 A4 A5 A6 A7 A8 A9 A10

  1. ________

  2. Don’t know

  3. Refused




Y N

A1 A2 A3 A4 A5 A6 A7 A8 A9 A10

  1. ________

  2. Don’t know

  3. Refused




Y N

A1 A2 A3 A4 A5 A6 A7 A8 A9 A10

  1. ________

  2. Don’t know

  3. Refused




Y N

A1 A2 A3 A4 A5 A6 A7 A8 A9 A10

  1. ________

  2. Don’t know

  3. Refused




Y N

A1 A2 A3 A4 A5 A6 A7 A8 A9 A10

  1. ________

  2. Don’t know

  3. Refused




Y N

A1 A2 A3 A4 A5 A6 A7 A8 A9 A10

  1. ________

  2. Don’t know

  3. Refused




Y N

A1 A2 A3 A4 A5 A6 A7 A8 A9 A10

  1. ________

  2. Don’t know

  3. Refused

Lighting Control Measures


Control Measure Type

<from tracking system>

LC1. Wattage Controlled

LC2. Hours/day before Control

LC3.

% Reduction in Operating Hours




  1. ________

  2. Don’t know

  3. Refused




  1. ________

  2. Don’t know

  3. Refused




  1. ________

  2. Don’t know

  3. Refused




  1. ________

  2. Don’t know

  3. Refused




  1. ________

  2. Don’t know

  3. Refused




  1. ________

  2. Don’t know

  3. Refused




  1. ________

  2. Don’t know

  3. Refused




  1. ________

  2. Don’t know

  3. Refused




  1. ________

  2. Don’t know

  3. 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:


  1. No idea

  2. Put into storage

  3. Installed at another facility

  4. Insufficient financial resources to complete

  5. Other (describe)_____________

  6. Don’t know

  7. Refused



1 2 3 4


5___________________


6 7

[Ask If L2 differs from quantity in trackers, else LR1]


LV2. Reason wattage differed:


  1. Put into storage

  2. Installed at another facility

  3. Insufficient financial resources to complete

  4. Other (describe)_____________

  5. Don’t know

  6. 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?


  1. Same

  2. More

  3. Less

  4. Don’t know

  5. Refused




1 2 3 4 5

[If LR2=2, else skip to LR4]

LR3. How fewer fixtures were installed?

  1. ________

  2. Don’t know

  3. Refused

[If LR2=2, else skip to LR8]

LR4. How many more fixtures installed?

  1. ________

  2. Don’t know

  3. Refused

LR 5. Estimated age of removed equipment


  1. ________

  2. Don’t know

  3. 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

  1. Number _________

  2. Don’t know

  3. Refused

O3. Facility’s square footage served by this equipment

  1. _________

  2. Don’t know

  3. 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

  1. <5 years old

  2. 5-10 years old

  3. 11-20 years old

  4. >20 years old

  5. Don’t know

  6. Refused


1 2 3 4 5 6

O7. Did you remove the same amount of equipment as installed?


  1. Same

  2. More

  3. Less

  4. Don’t know

  5. Refused




1 2 3 4 5


Notes:











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


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleSite ID #:
AuthorJessica Harrison
File Modified0000-00-00
File Created2021-01-30
© 2024 OMB.report | Privacy Policy