DOE HQ F 413.25 Home Energy Score - Home Energy Scoring Tool Data Collec

DOE HQ F 413.25
(03/2015)

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

Home Energy Scoring Tool
Data Collection Sheet
Location Information
Address: ________________________________ City: ________________ State: _____ Zip: ______
Assessment Type: Initial / Final / QA / Alternative EEM (Energy Efficiency Measures) / Test / Corrected

Assessment Date: _________________ Qualified Assessor: ______________________________
Comments: ________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
House Information
Year Built: _______________ # of Bedrooms: __________ # of Stories Above Grade: ___________
Average Ceiling Height (ft): ____________ Conditioned Floor Area (sq ft): _____________
Direction Faced by Front of House: N / NE / E / SE / S / SW / W / NW
Air Tightness
Was a Blower Door test conducted on this house?: Yes / No
Air Leakage rate: _______________ cfm50

Has the house been professionally air sealed?: Yes / No

Roof
Roof Construction: Standard Roof / with Radiant Barrier / with Rigid Foam Sheathing
Exterior Finish: Composition Shingles or Metal / Wood Shakes / Clay Tile / Concrete Tile / Tar & Gravel
Insulation Level (applied to roof): R-0 / R-11 / R-13 / R-15 / R-19 / R-21 / R-27
Roof Color: White / Light / Medium / Medium Dark / Dark / Cool Color: ______ (reflectivity)
Attic
Attic or Ceiling Type: Unconditioned Attic / Conditioned Attic / Cathedral Ceiling
Attic Floor Insulation: R-0 / R-3 / R-6 / R-9 / R-11 / R-19 / R-21 / R-25 / R-30 / R-38 / R-44 / R-49 / R-60

Foundation
Type: Slab-on-Grade / Unconditioned Basement / Conditioned Basement / Unvented Crawlspace /
Vented Crawlspace
Insulation over Basement or Crawlspace: R-0 / R-11 / R-13 / R-15 / R-19 / R-21 / R-25 / R-30 / R-38
Foundation Insulation: None / R-5 (slab only) / R-11 (bsmt/crawl wall) / R-19 (bsmt/crawl wall)
Walls
Is this home a Townhouse or Duplex?: Yes / No

Position of Unit: Middle / Left / Right

Wall Characteristics: Front or All (circle one)
Construction: Wood Frame / Wood Frame with rigid foam sheathing / Wood Frame with Optimum Value Engineering
(OVE) / Structural Brick / Concrete Block or Stone / Straw Bale
Exterior Finish: Wood Siding, Fiber Cement, Composite Shingle or Masonite Siding / Stucco / Vinyl Siding / Aluminum
Siding / Brick Veneer
Wall Insulation: R-0 / R-3 / R-7 / R-11 / R-13 / R-15 / R-19 / R-21 / R-27 / R-33 / R-38
Skylights: Yes or No (circle one):
Total Skylight Area (sq. ft.): __________ Number of Panes: ___________
Frame Type: Aluminum / Aluminum with Thermal Break / Wood or Vinyl
Glazing Type: Clear / Tinted / Solar-control low-E / Solar-control low-E, argon gas fill / Insulating low-E / Insulating low-E,
argon gas fill
-OR- Actual window specifications = U-Factor (from 0.01 – 5): _________ SHGC (from 0 – 1): ______
Window Area (sq. ft.):
Front: ____________

Back: _____________ Right Side: ___________

Left Side: ____________

Window Characteristics: Front or All (circle one)
Panes: Single-pane / Double-pane / Triple-pane
Frame Type: Aluminum / Aluminum with Thermal Break / Wood or Vinyl
Glazing Type: Clear / Tinted / Solar-control low-E / Solar-control low-E, argon gas fill / Insulating low-E / Insulating low-E,
argon gas fill
-OR- Actual window specifications = U-Factor (from 0.01 – 5): _________ SHGC (from 0 – 1): ______
Wall Characteristics: Back

Home Energy Score – Data Collection

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Revised 3/26/2015

Construction: Wood Frame / Wood Frame with Rigid Foam Sheathing / Wood Frame with Optimum Value Engineering
(OVE) / Structural Brick / Concrete Block or Stone / Straw Bale
Exterior Finish: Wood Siding, Fiber Cement, Composite Shingle or Masonite Siding / Stucco / Vinyl Siding / Aluminum
Siding / Brick Veneer
Wall Insulation: R-0 / R-3 / R-7 / R-11 / R-13 / R-15 / R-19 / R-21 / R-27 / R-33 / R-38
Window Characteristics: Back
Panes: Single-pane / Double-pane / Triple-pane
Frame Type: Aluminum / Aluminum with Thermal Break / Wood or Vinyl
Glazing Type: Clear / Tinted / Solar-control low-E / Solar-control low-E, argon gas fill / Insulating low-E / Insulating low-E,
argon gas fill
-OR- Actual window specifications = U-Factor (from 0.01 – 5): _________ SHGC (from 0 – 1): ______
Wall Characteristics: Right Side (facing house)
Construction: Wood Frame / Wood Frame with Rigid Foam Sheathing / Wood Frame with Optimum Value Engineering
(OVE) / Structural Brick / Concrete Block or Stone / Straw Bale
Exterior Finish: Wood Siding, Fiber Cement, Composite Shingle or Masonite Siding / Stucco / Vinyl Siding / Aluminum
Siding / Brick Veneer
Wall Insulation: R-0 / R-3 / R-7 / R-11 / R-13 / R-15 / R-19 / R-21 / R-27 / R-33 / R-38
Window Characteristics: Right Side (facing house)
Panes: Single-pane / Double-pane / Triple-pane
Frame Type: Aluminum / Aluminum with Thermal Break / Wood or Vinyl
Glazing Type: Clear / Tinted / Solar-control low-E / Solar-control low-E, argon gas fill / Insulating low-E / Insulating low-E,
argon gas fill
-OR- Actual window specifications = U-Factor (from 0.01 – 5): _________ SHGC (from 0 – 1): ______
Wall Characteristics: Left Side (facing house)
Construction: Wood Frame / Wood Frame with Rigid Foam Sheathing / Wood Frame with Optimum Value Engineering
(OVE) / Structural Brick / Concrete Block or Stone / Straw Bale
Exterior Finish: Wood Siding, Fiber Cement, Composite Shingle or Masonite Siding / Stucco / Vinyl Siding / Aluminum
Siding / Brick Veneer
Wall Insulation: R-0 / R-3 / R-7 / R-11 / R-13 / R-15 / R-19 / R-21 / R-27 / R-33 / R-38
Windows Characteristics: Left Side (facing house)
Panes: Single-pane / Double-pane / Triple-pane

Home Energy Score – Data Collection

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Revised 3/26/2015

Frame Type: Aluminum / Aluminum with Thermal Break / Wood or Vinyl
Glazing Type: Clear / Tinted / Solar-control low-E / Solar-control low-E, argon gas fill / Insulating low-E / Insulating low-E,
argon gas fill
-OR- Actual window specifications = U-Factor (from 0.01 – 5): _________ SHGC (from 0 – 1): ______
Heating System
Type of Heating System: None / Central gas furnace / Room (through-the-wall) gas furnace / Propane (LPG) furnace / Oil
furnace / Electric furnace / Electric heat pump / Electric baseboard heater / Gas boiler / Oil boiler / Ground coupled heat
pump / Propane (LPG) Boiler
Heating System Efficiency:
Do you know the actual heating system efficiency?: Yes / No (before answering “No”,
can you use the Home Energy Score Assessor Calculator to determine the approximate efficiency value?)
Efficiency Value (AFUE or HSPF): __________________ OR Year Installed: _____________________
Cooling System:
Type of Cooling System: None / Central air conditioner / Room air conditioner / Electric heat pump / Ground coupled
heat pump
Cooling System Efficiency:
Do you know the actual cooling system efficiency?: Yes / No (before answering “No”,
can you use the Home Energy Score Assessor Calculator to determine the approximate efficiency value?)
Efficiency Value (SEER or EER): __________________ OR Year Installed: _____________________
Ducts
Duct Location (#1): Conditioned Space / Unconditioned basement or unvented crawlspace / Vented crawlspace /
Unconditioned attic
Percentage of Ducts in this location: __________ Are ducts sealed?: Yes / No Are ducts insulated?: Yes / No
Duct Location (#2): Conditioned Space / Unconditioned basement or unvented crawlspace / Vented crawlspace /
Unconditioned attic
Percentage of Ducts in this location: __________ Are ducts sealed?: Yes / No Are ducts insulated?: Yes / No
Duct Location (#3): Conditioned Space / Unconditioned basement or unvented crawlspace / Vented crawlspace /
Unconditioned attic
Percentage of Ducts in this location: __________ Are ducts sealed?: Yes / No Are ducts insulated?: Yes / No
Hot Water:
Water Heater Type: Electric storage / Natural gas storage / LPG storage / Oil storage / Electric heat pump / Boiler with
tank-less coil / Boiler with indirect tank
Hot Water System Efficiency:
Do you know the actual water heater energy factor?: Yes / No (before answering “No”,
can you use the Home Energy Score Assessor Calculator to determine the approximate energy factor?)

Home Energy Score – Data Collection

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Revised 3/26/2015

Energy Factor (between 0-1): ___________________ OR Year Installed: _____________________

General Info:

Assessment Checklist

Year
# of bedrooms
Blower door test?
Professionally air sealed?
Window specs?
Outside
House Orientation
# of stories
Roof: Predominant exterior finish
Color
Walls: Same type on all sides?
Construction type
Exterior finish
Windows: Same on all sides?
Panes
Frame
Glazing
Inside
Attic
Roof Construction
Insulation type & amount
Air sealed?
Air handler present? Type and
year
Ducts?: Insulated? Sealed?

Home Energy Score – Data Collection

Upper Floor
Square feet
Ceiling Height
Skylights?
Windows
Main Floor
Square feet
Ceiling Height
Skylights?
Windows
Walls & insulation
Crawlspace - insulation type & amount
Ducts?: Insulated? Sealed?
Basement – Conditioned?
Square feet
Ceiling Height
Windows
Walls & insulation
HVAC Equipment
Type?
Year or SN?
Water Heater
Type?
Year or SN?
Notes:

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Revised 3/26/2015

Window Dimensions:
Front
Back

Right

Left

Layout:

Home Energy Score – Data Collection

Revised 3/26/2015

Public reporting burden for this collection of information is estimated to average 130 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 (1910XXXX), 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-XXXX), Washington, DC 20503.

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