DOE HQ F 413.2 Superior Energy Performance Improvement Report

Superior Energy PerformanceTM - Energy Performance Improvement Report
									OMB Control #: 1910-NEW. Form no. DOE HQ F 413.2
									Exp. Date: XX/XX/XXXX
	Identifying information:								Guidance
`	1	Company Name							Name of company that owns facility
	2	Unique Facility Name per SEP Certificate							Name of facility. For facilities located on sites with multiple facilities, please provide the unique name that distinguishes this facility
	3	SEP Enrollment Number							SEP Registration Number is assigned upon enrollment
	4	Facility zip code							Zip code where facility is located
	5	Facility boundaries							Please identify the boundary(ies), or how the "facility" was defined for this certification. Example responses include entire facility, subset of production lines, subset of energy consuming systems. See SEP Certification Protocol (http://www.energy.gov/eere/amo/downloads/superior-energy-performance-certification-protocol)
	6	Facility square footage (ft2)							Please provide an estimate of the square footage for the facility boundaries identified in the previous question
	7	Date SEP/ISO 50001 Stage 2 audit started (month/day/year)							Date SEP/ISO 50001 Stage 2 audit began
	8	Date Energy Performance Improvement Report completed (month/day/year)							Date this form (Energy Performance Improvement Report) was completed
	Facility contact:								Guidance
	9	First Name							First name of principal contact on facility energy management team
	10	Last Name							Last name of principal contact on facility energy management team
	11	Email							Email of principal contact on facility energy management team
	12	Phone							Phone number of principal contact on facility energy management team
	Verification Body contacts:
	SEP Lead Auditor								Guidance
	13	First Name							First name of SEP Lead Auditor
	14	Last Name							Last name of SEP Lead Auditor
	15	Email							Email of SEP Lead Auditor
	16	Phone							Phone number of SEP Lead Auditor
	17	Organization							SEP Verification Body to which the SEP Lead Auditor is affiliated
	SEP Performance Verifier								Guidance
	18	First Name							First name of SEP Performance Verifier
	19	Last Name							Last name of SEP Performance Verifier
	20	Email							Email of SEP Performance Verifier
	21	Phone							Phone number of SEP Performance Verifier
	22	Organization							SEP Verification Body to which the SEP Performance Verifier is affiliated
	Certification information:
			Start Month/yr	End Month/yr					Guidance
	23	Verified Baseline Period							Start and end month/yr of baseline period.
	24	Verified Reporting Period							Start and end month/yr of reporting period.
	25	Verified SEP Achievement Period							Start and end month/yr for the SEP achievement period.
									Guidance
	26	Certification date (month/day/yr)							Month, day, and year SEP certificate was issued by SEP Verification Body
	27	Verified Achievement Level (Silver, Gold, Platinum)							Please indicate SEP achievement level the facility received for this certification - Silver, Gold, or Platinum
	28	Verified Reporting Period Energy Performance Improvement % (defined as 1 minus SEnPI)							The Report Period Energy Peformance Improvement is calculated as 1 minus SEnPI where SEnPI is the Superior Performance Energy Performance Indicator for the facility over the reporting period. Source: SEP Measurement and Verficiation Protocol (http://www.energy.gov/eere/amo/downloads/superior-energy-performance-measurement-and-verification-protocol-industry)
	29	Did the model as verified meet the requirements of the SEP Measurement & Verification (M&V) Protocol? (y/n)							The model requirements can be found in the SEP M&V Protocol: http://www.energy.gov/eere/amo/downloads/superior-energy-performance-measurement-and-verification-protocol-industry. Please indicate if the model met the appropriate requirements.
	30	Which adjustment model method (forecast, backcast, chaining, standard conditions, other) was used as described in the SEP M&V Protocol?							The adjustment model method used to determine SEnPI. Source: SEP Measurement and Verficiation Protocol (http://www.energy.gov/eere/amo/downloads/superior-energy-performance-measurement-and-verification-protocol-industry)
	31	If "Other" was chosen, did the model require and attain prior approval by the SEP Administrator (y/n)?							All models used for determining energy performance improvements must be approved by the SEP Administrator. For model methods not outlined in the SEP M&V Protocol, please indicate if approval by the SEP Administrator was sought and granted.
	32	If Yes to 31, did the model as verified meet the M&V requirements set forth in the prior approval by the SEP Administrator (y/n)?							If approval to use an alternate model method was granted by the SEP Administrator, please indicate if the model used for verification met the M&V requirements outlined by the SEP Administrator
	33	Was the SEP Scorecard used (y/n)?							For this certification, please indicate if the facility used the SEP Scorecard
		If yes, please provide details of SEP Scorecard credits earned:							For facilities that did use the SEP Scorecard, please indicate the number of credits received in the focus areas listed. Please note that the Energy Management System (EM) Credits total and the Advanced Practices (AP) Credits total are autsummed based on the responses to the preceeding relevant questions. See SEP Scorecard (http://www.energy.gov/eere/amo/downloads/superior-energy-performance-industrial-facility-best-practice-scorecard)
		Energy Management System (EM) Credits
	34	Energy Data, Monitoting and Measurement (DM)
	35	Significant Energy Uses (SU)
	36	Energy Supply (ES)
	37	Management of Energy Opportunities (EO)
	38	System Sustainability (SS)
	39	Energy Management System (EM) Credits (total) - autocompleted	0
	40	Additional Energy Performance Improvement (AEP) Credits (total)
		Advanced Practices (AP) Credits
	41	Combined Heat and Power
	42	Renewable Energy Supply
	43	Superior Performance with Benchmarks
	44	Engagement of Supply Chain
	45	Emerging Technologies
	46	Advanced Practices (AP) Credits (total) - autocompleted	0
	List the versions of the SEP normative documents used in this verification:								Guidance
		Title of Normative Document	Version Used in the Verification (revision date)						Revision dates can be found on the cover of the normative document
	47	Superior Energy PerformanceTM Measurement and Verification Protocol
	48	Superior Energy PerformanceTM Industrial Facility Best Practice Scorecard or Superior Energy PerformanceTM Scorecard
	49	Superior Energy PerformanceTM Certification Protocol
	Actual and modeled energy consumption information:								Guidance
	Baseline period primary (source) energy consumption (MMBtu)		Actual	Modeled (if chaining or backcasting)	Specify fuel				For each energy source listed below, please provide the actual energy consumption in the baseline period. If the adjustment model method is backcasting or chaining, please provide the modeled baseline period consumption as well. For more information, please see the SEP Measurement and Verfiication Protocol.
	50	Total
	51	Electricity
	52	Natural gas
	53	Distillate or Light Fuel Oil (#1, 2, & 4)
	54	Residual or Heavy Fuel Oil (# 5, 6, Navy Special & Bunker C)
	55	Coal
	56	Coke
	57	Blast Furnace Gas
	58	Wood Waste
	59	Other Energy Source (please specify)							Please specify the "other energy source" by name
	60	Other Energy Source (please specify)							Please specify the "other energy source" by name
	61	Other Energy Source (please specify)							Please specify the "other energy source" by name
									Guidance
	Reporting period primary (source) energy consumption (MMBtu)		Actual	Modeled (if chaining or forecasting)	Specify fuel				For each energy source listed below, please provide the actual energy consumption in the reporting period. If the adjustement model method is forecasting or chaining, please provide the modeled reporting period consumption as well. For more information, please see the SEP Measurement and Verfiication Protocol.
	62	Total
	63	Electricity
	64	Natural gas
	65	Distillate or Light Fuel Oil (#1, 2, & 4)
	66	Residual or Heavy Fuel Oil (# 5, 6, Navy Special & Bunker C)
	67	Coal
	68	Coke
	69	Blast Furnace Gas
	70	Wood Waste
	71	Other Energy Source (please specify)							Please specify the "other energy source" by name
	72	Other Energy Source (please specify)							Please specify the "other energy source" by name
	73	Other Energy Source (please specify)							Please specify the "other energy source" by name
	74. Model validity and relevant Variables
		Energy source (choose from list)	If "other" please specify	R^2 for model of energy source	P-value for overall model fit	Relevant variables in model for the energy source (e.g., production, HDD, CDD. Etc.)	p-value for relevant variable in model for this energy source		Guidance
									For each modeled energy source, please provide the parameters to test model validity: R^2 value for the model for the energy source, the p-value for the overall model, the relevant variables included in the model for the energy source, and the p-vaue for each of the relevant variables. NOTE: Each modeled energy source will have one R^2 value, one overall model p-value, multiple relevant variables and a p-value for each relevant variable. The energy source, specification of "other", the R^2, and the overall model p-value, only needs to be completed for the first relevant variable entry, and does not need to be completed for successive relevant variable entries for the same model
			First ISO 50001 and SEP certification	ISO 50001 recertification and first SEP certification OR upgrade to SEP mid-ISO 50001 certification	ISO 50001 and SEP recertification				Guidance
	75	Certification status for this facility (check one box, and follow instructions for next steps per your selection)							Please indicate this facility's ISO 50001 and SEP certification history. Your answer to this question will determine which SEP Voluntary Cost/Benefit form we request the facility to complete next. All facilities are requested, but not required, to fill out one of SEP Voluntary Cost/Benefit Forms 1 - 3 as well as SEP Voluntary Cost/Benefit Form 4.
		Instructions for next steps	Please complete SEP Voluntary Cost/Benefit Form 1	Please complete SEP Voluntary Cost/Benefit Form 2	Please complete SEP Voluntary Cost/Benefit Form 3
		Public reporting burden for this collection of information is estimated to average 1.5 hours 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 & 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. 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.