DOE HQ F 413.1 Superior Energy Performance Application

DOE HQ F 413.1
(11/2014)

OMB Control #: 1910-NEW
Exp. Date: XX/XX/XXXX

Superior Energy Performance®
Application Form
Version 2.0: 12-05-2014

Contents

Overview ............................................................................................................................................................... 1
Application Form................................................................................................................................................... 3
Attachment A: SEP Scorecard Application Worksheet ....................................................................................... 12
Attachment B: Facility Certification Checklist ..................................................................................................... 14

Overview
The Superior Energy Performance® (SEP™) program provides a transparent, globally recognized system that
facilities can use to improve their energy management and performance. SEP builds on the ISO 50001
framework for an energy management system (EnMS) and provides targets for improvements in energy
performance.
Certification requires the use of the ISO 50001:2011 Energy management system-Requirements with
guidance for use standard (ISO 50001)—and the American National Standard, ANSI/MSE 50021, and its
normative references which specify energy performance criteria and additional requirements for the energy
management system. To become certified, facilities must conform to ISO 50001 and ANSI/MSE 50021,
improve energy performance, and undergo a SEP audit from an ANSI-ANAB accredited SEP Verification Body.
SEP offers Silver, Gold, and Platinum certification performance levels. SEP certification is valid for three years
as long as annual surveillance audits are completed. To continue SEP certification beyond three years,
facilities must apply for recertification and undergo a recertification audit.

APPLY
A facility will submit an application to the SEP Administrator once the EnMS has been implemented, the
energy performance improvement has been achieved, and the facility is prepared for the verification audit.
In the application form, applicants will provide information such as contact information, facility information,
models, and any alternative approaches used. This information helps the SEP Administrator understand the
basic approaches the facility has used and whether the applicant is requesting pre-approvals for any
alternative approaches.
Once the SEP Administrator reviews and approves the application, applicants will be notified, after which, the
SEP Administrator will provide the application package to the SEP Verification Body selected by the applicant.
•

How to apply:
o

o

For organizations and facilities that have already enrolled in SEP: If an enrollment form was
already submitted for your organization/facility, please review that form, update as necessary,
and submit it with the application. If you do not have access to the enrollment form that was
submitted for your organization/facility, please request a copy from the SEP Administrator.
For organizations/facilities that have not enrolled in SEP: Please complete and submit the
enrollment form (pages 3-5) as part of this application.

Superior Energy Performance®
http://energy.gov/eere/amo/superior-energy-performance

OMB Control #: 1910-NEW
Exp. Date: XX/XX/XXXX
Form no. DOE HQ F 413.1

Please submit the application forms to the SEP Administrator via email:
[email protected].
If you wish to use any of the alternative approaches listed on the SEP Pre-Approvals page
[http://energy.gov/eere/amo/pre-approvals-needed-alternative-approaches], we strongly encourage you to
submit any request form(s) to the SEP Administrator prior to submitting the application, due to the amount
of time necessary to review these requests. If you request pre-approval for alternate approaches at the same
time as you submit the application, the application process could be delayed.
For questions, contact the SEP Administrator: [email protected].

OMB BURDEN DISCLOSURE STATEMENT
Public reporting burden for this collection of information is estimated to average 1 hour per response for the
SEP Application Form, 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 & Privacy
Management Division, IM-23, Paperwork Reduction Project OMB Control #: 1910-NEW, 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 OMB Control #: 1910-NEW, Washington, DC 20503.
CONFIDENTIALITY
DOE maintains the confidentiality of proprietary energy and production related data as proprietary that is
submitted to the Superior Energy Performance (SEP) program by SEP certified facilities, to the fullest extent
of the law. Data included within the SEP Enrollment and Application forms, SEP Energy Performance
Improvement Report and SEP Voluntary Cost Benefit Form will not be released publicly. DOE will make public
the following information about each SEP certified facility:
1. Facility name
2. Facility location (city, state)
3. Verified Achievement Level (e.g., Silver, Gold, or Platinum)
4. Verified Reporting Period Energy Performance Improvement
5. Certification date (month/year)
DOE will, from time-to-time, publicly share aggregate, program-wide metrics, such as number of SEP certified
plants, and annual and cumulative SEP program energy savings.
All data provided to DOE is subject to the Freedom of Information Act (FOIA), however, DOE will notify
partners if a FOIA request has been submitted for which their data might be responsive. DOE will consult with
the partner and ensure the partner has an opportunity to inform DOE what data they view is proprietary.
DOE will review the partner’s suggestions and will not release to the public any data DOE deems proprietary.

2

Superior Energy Performance®
http://energy.gov/eere/amo/superior-energy-performance

Application Form

OMB Control #: 1910-NEW
Exp. Date: XX/XX/XXXX
Form no. DOE HQ F 413.1

Organizations will submit this application form to the SEP Administrator once the EnMS has been implemented and
the energy performance improvement has been achieved at a facility.
Please submit this form to the SEP Administrator via email: [email protected]. For questions,
contact the SEP Administrator: [email protected].

TYPE OF APPLICATION
☐ Enterprise-Wide Multi-Facility Application (This option is for organizations that are submitting an
application for multiple facilities to become SEP certified. If this option is checked, please fill out pages 6-13
for each facility.)
• Total Number of Facilities Applying for SEP: Click here to enter text.
Note: Each facility requires a separate SEP application and a separate SEP audit.
☐ Individual Facility Application
FACILITY STATEMENT
Click here to enter text. (name of facility and location) seeks to complete a:
☐ SEP Certified Partner certification audit (Stage 1 and Stage 2)
☐ SEP Certified Partner recertification audit (Note: for the application to qualify as recertification, it must be
submitted at least 6 months before the certificate expiration date.)

CONTACT INFORMATION
•

•

For facilities that have already enrolled in SEP: If an enrollment form was already submitted for this facility,
please review that form, update as necessary, and submit it with this application. If you do not have access to
that form, please request a copy from the SEP Administrator.
For facilities that have not enrolled in SEP: Please complete and submit the Superior Energy Performance
Enrollment Form (see page 3-5) as part of this application.

3

Superior Energy Performance®
http://energy.gov/eere/amo/superior-energy-performance

BASIC FACILITY AND ENERGY INFORMATION
Enrollment number:
(Assigned by the SEP Administrator upon
enrollment; if facility is enrolling and
applying at same time, leave blank)
Facility square footage:

OMB Control #: 1910-NEW
Exp. Date: XX/XX/XXXX
Form no. DOE HQ F 413.1

NAICS Code(s):
(http://www.census.gov/eos/www/naics/)
Information on site such as products or
services produced as applicable:
Number of employees 1:
Number of shifts:

Proposed scope for SEP and ISO 50001
certification:

Scope exclusions:

Any restrictions that may limit audits within
the proposed scope:

Number of and type energy sources:

Number of and description of significant
energy uses (SEUs):

1

The number of employees may not be the same as the number of effective personnel, which will be used by the chosen
SEP Verification Body to determine the number of audit days.

4

Superior Energy Performance®
http://energy.gov/eere/amo/superior-energy-performance

PRIMARY ENERGY CONSUMPTION FOR THE FACILITY

OMB Control #: 1910-NEW
Exp. Date: XX/XX/XXXX
Form no. DOE HQ F 413.1

Annual Total Primary Energy Consumption
Please check the appropriate category that indicates this facility’s annual total primary energy consumption during
the reporting period in both tables below:
Facility Annual Primary Energy Consumption Table 1 (per ANSI/MSE 50028:2012)
< 25,000 MMBTU/YR
Industrial Light
25,000 to 500,000 MMBTU/Year
Industrial Medium
> 500,000 MMBTU/YR
Industrial Heavy
> 500,000 MMBTU/YR (e.g. refineries, complex chemical sites)
Industrial Very Heavy
Facility Annual Primary Energy Consumption Table 2* (per ISO 50003:2014)
< 189,563 MMBTU/Year (200 Terajoules/Year)
189,563 to 1,895,626 MMBTU/Year (200 to 2,000 Terajoules/Year)
1,895,627 to 9,478,133 MMBTU/Year (2,000 to 10,000 Terajoules/Year)
> 9,478,133 MMBTU/Year (10,000 Terajoules/Year)
* Conversion factor: 1 MMBTU = 0.00105506 Terajoules

☐
☐
☐
☐

☐
☐
☐
☐

Energy Sources
Please list this facility’s energy sources and associated reporting period primary energy consumption (in MMBTU) for
each source in the table below for the reporting period. (A table for converting delivered energy to primary energy is
located in the Superior Energy Performance Measurement and Verification Protocol for Industry.)
Additional instructions:
• Other energy sources: Add other energy sources in the lines near the bottom of the table.
• Secondary energy sources: Please do not list secondary energy sources (e.g., on-site generated steam) that
are derived from primary sources.
• Total: The sum of items in this table should be listed in the “Total” line at the bottom of the table. The total
should fall within the same range as indicated in the “Annual Total Primary Energy Consumption” tables
above.
Annual Facility Primary Energy
Consumption
Reporting Period
MMBTU/Year

Energy Source
Purchased Electricity—

Expressed by multiplying the delivered BTU by a source conversion
factor of 3

Natural Gas
Distillate or Light Fuel Oil (#1, 2, & 4)
Residual or Heavy Fuel Oil (# 5, 6, Navy Special & Bunker C)
Coal
Coke
Blast Furnace Gas
Wood Waste
Bio-Fuel
5

Superior Energy Performance®
http://energy.gov/eere/amo/superior-energy-performance
Propane
Gasoline
Purchased Steam
Purchased Compressed Air
Purchased Chilled Water
Purchased Hot Water
Solar
Wind
Other: Click here to enter text.
Other: Click here to enter text.
Other: Click here to enter text.
Total:

6

OMB Control #: 1910-NEW
Exp. Date: XX/XX/XXXX
Form no. DOE HQ F 413.1

Superior Energy Performance®
http://energy.gov/eere/amo/superior-energy-performance
Please answer the following questions.

OMB Control #: 1910-NEW
Exp. Date: XX/XX/XXXX
Form no. DOE HQ F 413.1

1. Is this facility currently certified to any other ISO management system standard?
a. ☐ Yes

☐ No

b. If Yes, which ISO standard(s)? Click here to enter text.
c.

If Yes, please provide the scope of that certification:
Click here to enter text.

d. (Optional) If Yes, the certification body is: Click here to enter text.
2. Please list the following information for the facility:
a. Baseline Period (MM/YY – MM/YY):

Click here to enter text.

b. Reporting Period (MM/YY – MM/YY):

Click here to enter text.

c.

Click here to enter text.

Achievement Period (number of years):

d. Is the facility using a shorter time period and meets the criteria as described in the SEP Measurement and
Verification Protocol?
☐ Yes

☐ No

If yes, list time period length: Click here to enter text.
e. Estimated energy performance improvement for the achievement period (rounded to nearest tenth):
Click here to enter text.%
Note: This is to provide an idea of the range of energy performance improvement and the facility is not
committing to this % improvement. The final energy performance improvement achieved and verified by the
SEP Verification Body will be published on the SEP web site.
f.

Pathway (if applicable): Click here to enter text.

g.

Will this facility be claiming Scorecard credits?
☐ Yes

☐ No

If Yes, please fill out Attachment A.

7

Superior Energy Performance®
http://energy.gov/eere/amo/superior-energy-performance

OMB Control #: 1910-NEW
Exp. Date: XX/XX/XXXX
Form no. DOE HQ F 413.1
3. This question refers to the SEP Energy Performance Indicator (SEnPI), which is defined in the SEP Measurement
and Verification Protocol for Industry. In determining the SEnPI, select the method that the facility used:
(Please select one.)
☐ Linear regression model
☐ Forecast
☐ Backcast
☐ Standard conditions
☐ SEnPI chaining
☐ Ratio of energy consumption to single production level

Note: Use of the “ratio of energy consumption to single production level” requires the ability to meaningfully
represent all output in a single quantity, such as total tons or gallons per year. However, in most cases, the
consumption depends on more than one production quantity and may also depend on additional factors including
weather and non-production related energy consumption. In these cases, this approach would not be appropriate.
Evidence must be provided to support the claim of only one relevant variable and that the ratio form is adequately
predictive of energy performance.
☐ Complex regression model
☐ Polynomial model
☐ General nonlinear model
☐ Other model (Note: all other model options require review and approval by the SEP Administrator in

advance of the Stage 1 audit. See the Measurement and Verification Protocol for more details.)

Note: Any rationale for using a complex regression model that differs from those listed in the SEP Measurement
and Verification Protocol must be submitted to the SEP Administrator for pre-approval prior to or with the
application. [See question 4]

If alternative approaches that require pre-approval from the SEP Administrator are being used, please answer
question 4. Please see the SEP web site for more information on alternative approaches and to download the
related forms: [http://energy.gov/eere/amo/pre-approvals-needed-alternative-approaches].
4. All alternative approaches must be pre-approved by the SEP Administrator. Request for Pre-Approval Forms
mentioned here can be downloaded from the SEP website and should be completed and emailed to the SEP
Administrator ([email protected]). (Please select all that apply.)
☐ The organization proposes to use data reporting intervals that are more frequent than weekly. See the SEP
Measurement and Verification Protocol for more details. [See Request for Pre-Approval Form 1]

For SEP Administrator only: Approved on Click here to enter a date.

☐The methodology and calculation for derived energy sources proposed is not listed in the SEP
Measurement and Verification Protocol. [See Request for Pre-Approval Form 2]
For SEP Administrator only: Approved on Click here to enter a date.
☐ Other rationale for using a complex regression model not listed in the SEP Measurement and Verification

Protocol. [See Request for Pre-Approval Form 3]

For SEP Administrator only: Approved on Click here to enter a date.
☐ Alternative adjustment model application methodologies, under the conditions of the SEP Measurement
and Verification Protocol for more details. [See Request for Pre-Approval Form 4]

For SEP Administrator only: Approved on Click here to enter a date.

8

Superior Energy Performance®
http://energy.gov/eere/amo/superior-energy-performance

OMB Control #: 1910-NEW
Exp. Date: XX/XX/XXXX
Form no. DOE HQ F 413.1
☐ Justification of circumstances, where a model does not satisfy all the explicit model validity requirements
specified in the SEP Measurement and Verification Protocol. See the SEP Measurement and Verification
Protocol for more details. [See Request for Pre-Approval Form 5]
For SEP Administrator only: Approved on Click here to enter a date.
☐ Justification of non-routine adjustments, including calculations (as noted in the SEP Measurement and

Verification Protocol). [See Request for Pre-Approval Form 6]

For SEP Administrator only: Approved on Click here to enter a date.
☐ Justification of other situations for adjustments not addressed explicitly in the SEP Measurement and
Verification Protocol, including calculations (as noted in the SEP Measurement and Verification Protocol).
[See Request for Pre-Approval Form 7]

For SEP Administrator only: Approved on Click here to enter a date.
☐ Use of a Scorecard credit that requires SEP Administrator approval. See SEP Scorecard for more details.

[See Request for Pre-Approval Form 8]

For SEP Administrator only: Approved on Click here to enter a date.
Note: Applicants are strongly encouraged to submit their Request for Pre-Approval Form(s) prior to submitting the
application to avoid delays in the application process; however these forms are also accepted when the application
is submitted.

5. Did this facility use the optional EnPI Tool available on the DOE website
[http://www.energy.gov/eere/amo/articles/energy-performance-indicator] to determine the SEnPI?
a. ☐Yes
☐No
6. Has this facility used consulting services to assist in determining the SEnPI?
a. ☐Yes
☐No
b. If Yes, Please provide details about the specific consulting service(s):
Click here to enter text.
7. Does this facility have any outsourced processes affecting energy use and consumption that are within the
EnMS scope and boundaries?
a. ☐Yes
☐No
b. If Yes, what are these outsourced processes?
Click here to enter text.
8. Have you selected a SEP Verification Body? Visit the SEP web site for a list of approved Verification Bodies:
[http://www.energy.gov/eere/amo/sep-and-iso-50001-certification-process#choose-a-VB]
a. ☐Yes
☐No
b. If Yes, please provide:
SEP Verification Body name: Click here to enter text.
If you work with a specific individual at the SEP Verification Body, please provide that person’s name,
email, and phone: Click here to enter text.
c. If No, please select a SEP Verification Body and notify the SEP Administrator as soon as possible.

9

Superior Energy Performance®
http://energy.gov/eere/amo/superior-energy-performance
If this facility is not seeking SEP recertification, skip to question 10.

OMB Control #: 1910-NEW
Exp. Date: XX/XX/XXXX
Form no. DOE HQ F 413.1

9. If this is an application for recertification, please answer the following questions.
a. What is this facility’s current certificate number (located on certificate issued by the SEP Verification
Body)? Click here to enter text.
b. When was this facility’s initial certification date? Click here to enter a date.
c.

When was this facility’s most recent surveillance audit? Click here to enter a date.

d. Who was this facility’s SEP Verification Body for the previous certification? Click here to enter text.
e. Will this facility be keeping the same SEP Verification Body?
☐Yes

☐No

If No, please list this facility’s new SEP Verification Body here: Click here to enter text.
f.

What was this facility’s last certification Energy Performance level?
☐Silver

☐Gold

☐Platinum

g. What was this facility’s last certification baseline period (MM/YY - MM/YY)? Click here to enter text.
h. Are there changes to the certification scope for this facility?
(Note: This will require a Stage 1 audit for recertification)

☐Yes
i.

☐No

Is this facility using a different type of model to determine the SEP Energy Performance Indicator (SEnPI)?
(Note: This may require a Stage 1 audit for recertification)
☐ Yes

☐No

10. Surveillance and Certification Renewal Requirements
☐I acknowledge that there will be annual surveillance to confirm that the energy management system is being
maintained and continual improvement of energy performance is supported. These audits will assess the
continued effectiveness of the energy management system (not a re-assessment of the energy performance).
☐I also acknowledge that this certification is valid for three years following the date that my SEP certificate is
issued by the Verification Body.
Name of individual submitting this application: Click here to enter text.
Title: Click here to enter text.
Address: Click here to enter text.
Phone Number: Click here to enter text.
Email Address: Click here to enter text.
Date: Click here to enter a date.
Name of individual authorizing this application: Click here to enter text.
Title: Click here to enter text.
Address: Click here to enter text.
Phone Number: Click here to enter text.
Email Address: Click here to enter text.
Date: Click here to enter a date.

10

Superior Energy Performance®
http://energy.gov/eere/amo/superior-energy-performance

OMB Control #: 1910-NEW
Exp. Date: XX/XX/XXXX
Form no. DOE HQ F 413.1

Please include any other facility applications below this point.
----------------------------------------------------

11

Superior Energy Performance®
http://energy.gov/eere/amo/superior-energy-performance

Attachment A: SEP Scorecard Application Worksheet

OMB Control #: 1910-NEW
Exp. Date: XX/XX/XXXX
Form no. DOE HQ F 413.1

If the Scorecard is applicable, please complete the table below, noting which Scorecard credits are being claimed and
will be audited. The Scorecard Application Worksheet can also be downloaded from the SEP website.
Scorecard Credit Name
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
12

Superior Energy Performance®
http://energy.gov/eere/amo/superior-energy-performance
27
28
29
30

13

OMB Control #: 1910-NEW
Exp. Date: XX/XX/XXXX
Form no. DOE HQ F 413.1

Superior Energy Performance®
http://energy.gov/eere/amo/superior-energy-performance

Attachment B: Facility Certification Checklist

OMB Control #: 1910-NEW
Exp. Date: XX/XX/XXXX
Form no. DOE HQ F 413.1

This checklist has been prepared as an informal guide for facilities applying to the SEP certification program. Use of
this checklist is not required.

Certified Partner: ANSI-ANAB Accredited Certification Checklist
☐

Have you contacted the SEP Administrator and enrolled in SEP?

☐

Have you contacted the SEP Administrator and received pre-approval(s) for any alternative approach(es) used?

☐

Have you contacted the SEP Administrator and submitted an application to be a SEP Certified Partner?

Have you selected an ANSI-ANAB accredited or applicant SEP Verification Body to conduct the SEP conformity audit
[http://www.energy.gov/eere/amo/sep-and-iso-50001-certification-process#choose-a-VB]?

☐

Has the selected SEP Verification Body conducted a SEP conformity audit, which includes a Stage 1 audit to confirm
whether the facility is prepared for the Stage 2 audit?

☐

Has the selected SEP Verification Body sent a SEP Lead Auditor and SEP Performance Verifier(s) to the facility to
perform a Stage 2 audit assessing the following?

☐

☐

Conformance to ISO 50001 and ANSI/MSE 50021

☐

Energy performance improvement verified using the SEP Measurement and Verification Protocol

☐ Has the SEP Verification Body informed the SEP Administrator whether the facility has met the requirements for
certification to ISO 50001 and ANSI/MSE 50021 including the specified energy performance improvement and
whether a certificate will be issued to the SEP Certified Partner applicant?
☐

Has the SEP Administrator posted the results of the certification decision on the SEP web site?

14