Better Buildings, Better Buildings, Better Plants In-Plant Evaluati

OMB Control Number - 1910-5141

Form Exp. Date - 8/31/2015

E valuation Form (2 Pages Total)

In-Plant Training on [Specify System Type] Systems

Training Site: Plant Name, City, State

Date: (M/D/Y) - (M/D/Y)

Please Complete and return to your Technical Account Manager (TAM) at the conclusion of this In-Plant Training

Participant Name: Job Title:

Organization/Address: Phone: Email:

Are you responsible for managing energy costs at your organization? YES / NO. If YES, please indicate Plant Level or Corporate Level:

1.0 What is your principal business type? Mark only one.

1. Manufacturer 3. Utility (Natural Gas) 5. Utility (Water or Other) 7. Other (Specify) ___

2. State Agency - Energy Efficiency Program 4. Utility (Electricity) 6. Industrial Assessment Center (IAC)

2.0 What industry or industries do you work in (if applicable)? Check all that apply.

10. Petroleum

10. Steel

12. Other __________

1. Agriculture	4.	Food Processing	7.	Glass
2. Aluminum	5.	Forest Products	8.	Metal Casting
3. Chemical	6.	Textiles	9.	Mining

3.0 What is your main reason for attendance?

1. Acquire New Skills 2.Interest in Topic Area 3.Required by Employer 4.Update Skills 5. Job-Related Incentive 6. Other_____

4.0	Participants feedback on In-Plant Training (INPLT):	Strongly Disagree		Neither Agree Nor Disagree		Strongly Agree
4.1	The INPLT provided information that I will apply to my job	1	2	3	4	5
4.2	The INPLT provided adequate time for asking questions & discussion.	1	2	3	4	5
4.3	The Energy Expert(s) made clear the goals-objectives of the in-plant training	1	2	3	4	5
4.4	The Energy Expert(s) used effective teaching & training methods.	1	2	3	4	5
4.5	The Energy Expert(s) covered the training objectives.	1	2	3	4	5
4.6	The Energy Expert(s) responded to the questions and issues effectively	1	2	3	4	5
4.7	Plant tour was helpful in demonstrating information presented in classroom training	1	2	3	4	5

5.0	How effective was the workshop at providing information on:	Not Effective		Moderately Effective		Very Effective	Not Applicable
5.1	Identifying opportunities for improving [SPECIFY SYSTEM TYPE] system efficiency.	1	2	3	4	5	N/A
5.2	Factors affecting [SPECIFY SYSTEM TYPE] system efficiency.	1	2	3	4	5	N/A
5.3	Methods of managing [SPECIFY SYSTEM TYPE] system efficiency	1	2	3	4	5	N/A
5.4	Energy and economic analysis techniques for [SPECIFY SYSTEM TYPE] systems.	1	2	3	4	5	N/A
5.5	Useful software applications for [SPECIFY SYSTEM TYPE] systems.	1	2	3	4	5	N/A
5.6	Operation, selection & maintenance of [SPECIFY SYSTEM TYPE] system equipment	1	2	3	4	5	N/A

6.0 Other Comments:

6.1 Would you recommend this INPLT to other Plant(s) in your organization?	Yes / No
6.2 What actions do you expect to take as a result of this training?
6.3 As a result of this training, do you feel comfortable using the [SPECIFY SYSTEM TYPE] System Assessment Tool Software?	Yes / No
6.4 What are your comments or suggestions for improving this INPLT on [SPECIFY SYSTEM TYPE]?

7. Based on what I learned today, I will implement some energy savings Best Practices when I go back to my plant

1 2 3 4 5

    

Strongly Disagree Agree Strongly Agree

Comments: Best Practices, I intend to pursue in my plant are:

7.1 ----------------------------------------------------------------------------------------

7.2 ----------------------------------------------------------------------------------------

7.3 ----------------------------------------------------------------------------------------

7.4 ----------------------------------------------------------------------------------------

7.5 ----------------------------------------------------------------------------------------

7. My facility has decided to pursue implementation, or is beginning to implement the ISO 50001 energy management standard:

Yes / No

7. Would you like to be contacted about the following DOE Technical Assistance programs:

Combined Heat and Power (CHP)? Yes / No

Industrial Assessment Centers (IAC)? Yes / No

Superior Energy Performance (SEP)? Yes / No

10. Can DOE follow up with you in about a year to see what practices you have put in place as a result of this INPLT?

Yes / No

Public reporting burden for this collection of information is estimated to average 15 minutes 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-23, Paperwork Reduction Project (1910-5141), 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 (1910-5141), Washington, DC 20503.

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