Form DOE HQ F 413.37 DOE HQ F 413.37 SEP 50001 Application

Superior Energy Performance 50001™ OMB Control #: 1910-5177

www.energy.gov/SEP50001 Exp. Date: 10/31/2021

Form no. DOE HQ F 413.37

Superior Energy Performance 50001™
Application: 2019

Version 3.0: 05-17-2019

Contents

Introduction 1

Application 2

Section 1: Overview 2

Section 2: Facility Information 3

Section 3: Optional for Each Facility 7

OMB Burden Disclosure Statement and Confidentiality 9

Introduction

Superior Energy Performance 50001™ (SEP 50001™) is program that recognizes excellence in energy management systems (EnMS) by certification of a facility’s implementation of the International Organization for Standardization (ISO) 50001 Energy management system-Requirements with guidance for use standard (ISO 50001) EnMS and additional SEP 50001 requirements. Organizations that achieve ISO 50001 receive accredited third party certificates. Organizations that achieve SEP 50001 receive accredited certification from third-party verification bodies, under the ANSI-ASQ National Accreditation Board (ANAB). Additional recognition from the SEP 50001 Program Administrator is available for those organizations that use the SEP 50001 Scorecard and submit a SEP 50001 Scorecard Declaration.

Within the United States, the SEP 50001 Program Administrator is the US Department of Energy (US DOE). The US DOE describes its recognition of SEP 50001-certified facilities on the SEP 50001 website. Government agencies in other countries may create similar recognition and award programs specific to their country, but US DOE does not administer SEP 50001 recognition to organizations located outside of the United States.

Apply

This document is the application for the SEP 50001 (2019) version of the program¹. A facility will submit this application to the SEP 50001 Program Administrator (Administrator) after the EnMS has been implemented, the energy performance improvement has been achieved, and the facility is prepared for the verification audit. Applicants will provide contact information, facility information, model type, and any alternative approaches used. This information helps the Administrator understand the basic approaches the facility used and whether the applicant is requesting approvals for any alternative approaches. Due to the timeframes needed to approve the application and schedule an audit team with the appropriate competencies, applications should be submitted six (6) months—and no less than three (3) months—prior to the timeframe that the organization wants to be audited.

If you wish to use any of the alternative approaches listed on the Approvals page [https://betterbuildingssolutioncenter.energy.gov/resources/sep-50001-forms-pre-approvals-alternative-approaches], we strongly encourage you to submit any request form(s) to the Administrator prior to submitting the application, so the alternative approaches can be approved prior to submission of the application to the SEP 50001 Verification Body. If you request approval for alternate approaches at the same time as you submit the application, the application process, then expect a two-week delay in processing the application.

The Administrator will review the application and notify the applicant upon approval. The Administrator will then provide the application package to the SEP 50001 Verification Body selected by the applicant. Submit the completed application or questions to the Administrator via email: [email protected].

Application

Please submit the application to the Administrator: [email protected].

Section 1: Overview

Type of Application

1. Please select the type of application below

☐ Individual Facility Application

☐ Central Function Application

(This option is for organizations that are submitting an application for multiple facilities to become SEP 50001-certified under a central function. If this option is checked, please fill out Section 2-3 for each facility.)

1. Central office function: Click here to enter text.

   • Is this a permanent location? ☐Yes ☐No

   • Is this a virtual location? ☐Yes ☐No

2. Total number of facilities applying for SEP 50001: Click here to enter text.

3. Are these facilities being added to an existing ISO 50001 certificate?

☐Yes ☐No

☐ Close Geographic Proximity Site Application (Campus)

(This option is for organizations that are submitting an application for multiple sites within close geographic proximity that will apply as one facility for SEP 50001, see ANSI/MSE 50028-1:2019, Annex A.1.1 for more details.)

1. Number of sites under this facility: Click here to enter text.

2. Number of utility electric and gas revenue meters under this facility: Click here to enter text.

3. Distance between sites: Click here to enter text.

4. Typical mode of transportation between sites (e.g., walking, golf cart, car):

Click here to enter text.

5. Is there a unique energy type at any of these sites? Please describe. Click here to enter text.

Main Organization Contact Information

2. Please enter the information for the organization’s main contact below.

1. Organization Name: Click here to enter text.

2. Parent Company Name (if applicable): Click here to enter text.

3. Organization Contact Name: Click here to enter text.

4. Contact Title: Click here to enter text.

5. Main Contact Address: Click here to enter text.

6. City, State, Zip Code: Click here to enter text.

7. Phone Number: Click here to enter text.

8. Email Address: Click here to enter text.

Section 2: Facility Information

Facility Statement

3. Click here to enter text. (name of facility and location) seeks to complete a:

☐ SEP 50001 certification audit

☐ SEP 50001 recertification audit
(Note: To avoid a lapse in SEP 50001 certification, it is recommended the applicant submit 6 months before the certificate expiration date. An application submitted less than 3 months prior to the certification expiration date is the latest acceptable submission and may not prevent a lapse in certification.)

1. For recertification, please answer the following questions.

   1. When was this facility’s initial SEP 50001 certification date? Click here to enter a date.

   2. What was this facility’s last SEP 50001 certification baseline period (MM/YY - MM/YY)?

Click here to enter text.

3. Are there changes to the SEP 50001 certification scope for this facility?

(Note: This will require a Stage 1 audit for recertification)

☐ Yes ☐ No

Facility Contact Information

4. Facility Contact Information*

1. Facility Name: Click here to enter text.

2. Street Address: Click here to enter text.

3. Mailing Address: (if different than street address) Click here to enter text.

4. City, State, Zip Code: Click here to enter text.

5. Country: Click here to enter text.

6. Is the facility contact the same organizational contact listed in question 2?

☐ Yes ☐ No

If Yes, skip to next question. If No, fill in g-j.

7. Contact Name: Click here to enter text.

8. Contact Title: Click here to enter text.

9. Phone Number: Click here to enter text.

10. Email Address: Click here to enter text.

*If “Close Geographic Proximity Site (Campus) Application” was selected in question 1, please copy and paste 4a-4e and provide the information for each site included in the facility boundaries before the next question.

Basic Facility Information

5. Facility Information

   1. NAICS Code(s): Click here to enter text.

   2. Square footage: Click here to enter text.

   3. Number of employees: Click here to enter text.

   4. Number of EnMS effective personnel:² Click here to enter text.

   5. Number of shifts: Click here to enter text.

   6. Information such as products or services produced as applicable:

Click here to enter text.

6. Scope and Audit

   1. Scope for SEP 50001 certification (and please note if the scope for SEP 50001 is different than ISO 50001):

Click here to enter text.

2. Scope non-applicability (if applicable): Click here to enter text.

3. Any restrictions that may limit audits within the proposed scope (e.g., security limitations):

Click here to enter text.

4. Is this facility currently certified to ISO 50001?

☐ Yes (answer i-iii below) ☐ No (continue to part e)

1. Please provide the ISO 50001 scope (or note “same as 6a”):

Click here to enter text.

2. Certification Body for current ISO 50001 certification: Click here to enter text.

3. For your SEP 50001 certification, will you be recertifying to ISO 50001 at the same time?

☐ Yes ☐ No

5. Have you selected a SEP 50001 Verification Body?³

☐ Yes (answer i-ii below) ☐ No (Skip to next question. Please select a SEP 50001 Verification Body and notify the Administrator as soon as possible.)

1. Please provide:

• SEP 50001 Verification Body name: Click here to enter text.

• If you work with a specific individual at the Verification Body, please provide that person’s name, email, and phone: Click here to enter text.

2. If this is a SEP 50001 recertification audit, are you keeping the same Verification Body?

☐Yes ☐No ☐N/A

Facility Energy Information

7. Energy types and significant energy uses:

   1. Number of and list of energy types: Click here to enter text.

   2. Number of significant energy uses (SEUs): Click here to enter text.

8. Please check in Table 1 below the appropriate category that indicates this facility’s total annual site energy consumption during the reporting period⁴

Table 1 - Facility Annual Site Energy Consumption* (per ISO 50003)

≤ 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 million British thermal units (MMBTU) = 0.00105506 Terajoules

9. Time Periods and Energy Performance Improvement

   1. Baseline Period (MM/YY – MM/YY): Click here to enter text.

   2. Reporting Period (MM/YY – MM/YY): Click here to enter text.

   3. Achievement Period length: ☐ 1 year ☐ 2 years ☐ 3 years

   4. 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 facility has the choice to have the verified final energy performance improvement or absolute value of energy savings in BTU achieved published on the SEP 50001 website.

10. Adjustment Model

This question refers to the SEP 50001 Energy Performance Indicator (SEnPI), which is defined in the SEP 50001 Program Measurement and Verification Protocol: 2019 (M&V Protocol). 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 relevant variable

Note: Use of the “ratio of energy consumption to single relevant variable” 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 variable 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

(Note: use of a complex regression model requires review and approval by the Administrator in advance of the Stage 1 audit. See the M&V Protocol for more details.)

Alternative Approaches

If the facility used alternative approaches from the SEP 50001 M&V Protocol or SEP 50001 Certification Protocol that require approval from the Administrator, please answer this question. All alternative approaches must be approved by the Administrator. For more information on alternative approaches and to download forms, visit:

[https://betterbuildingssolutioncenter.energy.gov/resources/sep-50001-forms-pre-approvals-alternative-approaches]. Send the completed Request for Approval Form(s) to the Administrator ([email protected]).

11. Request to use alternative approach (Please select all that apply.)

Note: Applicants are strongly encouraged to submit their Request for 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.

☐ Site-specific or other derived energy type multipliers proposed not listed in Annex B of the SEP 50001 Program M&V Protocol: 2019 [Section 5.1.1, Annex B]. [See SEP 50001 Request for Approval Form 1]

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

☐ Justification of non-routine adjustments, including calculations [Section 5.3.2 in the SEP 50001 Program M&V Protocol: 2019]. [See SEP 50001 Request for Approval Form 2]

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

☐ Use of a complex regression model, including rationale [Section 6.3.2 in the SEP 50001 Program M&V Protocol: 2019]. [See SEP 50001 Request for Approval Form 3]

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

☐ Any other alternative approaches, deviations from SEP 50001 Program M&V Protocol requirements, or situations that require review and approval by the Administrator [Section 1.1]. [See SEP 50001 Request for Approval Form 4]

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

☐ For organizations combining existing SEP certified sites onto a signle SEP 50001 multi-site certificate and require a baseline adjustment for one or more facilities [SEP 50001 Certification Protocol, Section 5.2.2]. [See SEP 50001 Request for Approval Form 5]

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

Application Submission

Individual submitting this application: ☐ Main Organizational Contact ☐ Facility Contact ☐ Other

Name: 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.

Individual authorizing this application: ☐ Main Organizational Contact ☐ Facility Contact ☐ Other

Name: 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.

Section 3: Optional for Each Facility

12. Does this facility have experience with other ISO management systems?

    1. ☐ Yes (complete b) ☐ No (skip to next question)

    2. Which ISO management systems? (Please select all that apply.)

☐ ISO 9001 ☐ ISO 14001 ☐ Other: Click here to enter text.

13. What is this facility’s estimated total annual energy bill?

Annual Total Energy Bill
☐	< $500,000/Yr
☐	$500,000 to $1,000,000/Yr
☐	$1,000,001 to $2,000,000/Yr
☐	$2,000,001 to $5,000,000/Yr
☐	> $5,000,000/Yr
☐	Not sure

14. Does this facility have a dedicated energy manager⁵?

☐ Yes ☐ No

15. Have you used any of the following energy management resources in your energy management program implementation? (Please select all that apply.)

☐ DOE AMO Energy Resource Center (e.g., Energy Performance Indicator Tool, 50001 Ready Navigator)

☐ ENERGY STAR energy management guidelines and tools

☐ Electric or gas utility strategic energy management technical assistance or rebates

☐ External energy consultant

☐ Energy equipment supplier or service provider

☐ Other: Click here to enter text.

16. What factors motivate your organization’s decision to pursue SEP 50001? (Please select all that apply.)

☐ Energy cost reduction

☐ Customer demand for energy and sustainability practices

☐ Corporate reputation

☐ Greenhouse gas emission reduction

☐ External validation of energy saving

☐ Other: Click here to enter text.

17. Name of this facility’s gas utility: Click here to enter text.

18. Name of this facility’s electric utility: Click here to enter text.

19. We will provide you with periodic informational emails. To add members of this facility’s energy management team on these emails, please list their names, email addresses, and roles below.

Name: Click here to enter text.

Email: Click here to enter text.

Role: Click here to enter text.

Name: Click here to enter text.

Email: Click here to enter text.

Role: Click here to enter text.

Name: Click here to enter text.

Email: Click here to enter text.

Role: Click here to enter text.

Name: Click here to enter text.

Email: Click here to enter text.

Role: Click here to enter text.

For a Central Function Application, please include any other facility applications below this point.

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<END OF APPLICATION>

OMB Burden Disclosure Statement and Confidentiality

OMB Burden Disclosure Statement

This data is being collected to facilitate delivery of technical assistance and other program services. The data you supply will be used to evaluate the effectiveness of investments in energy management systems and to improve the usefulness of Federal technical assistance and recognition programs.

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, Enterprise Policy Development & Implementation Office, IM-22, Paperwork Reduction Project OMB control number 1910-5177, 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 number 1910-5177, Washington, DC  20503.

Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB control number.

Submission of this data is voluntary.

Confidentiality

The U.S. Department of Energy (US DOE), as the SEP 50001 Program Administrator within the United States, maintains the confidentiality of proprietary energy and production related data as proprietary that is submitted to the SEP 50001 program by SEP 50001-certified facilities, to the fullest extent of U.S. federal law. Data included within the SEP 50001 Application, SEP 50001 Energy Performance Improvement Report, and any other forms or data shared with the US DOE will not be released publicly. The US DOE will publicly report the following information about each SEP 50001-certified facility:

1. Facility name

2. Facility location (city, state)

3. Verified achievement period energy performance improvement

   1. The SEP 50001-certified facility can elect if energy performance improvement is reported, or not. If the energy performance improvement is reported, the facility has the option to report as an absolute value of energy savings (British thermal units (BTU)), a percentage value as compared to the energy baseline (SEnPI), or both.

4. Verified achievement period length

5. Certification date (month/year)

US DOE will, from time-to-time, publicly share aggregate, program-wide metrics, such as the number of SEP 50001-certified facilities, and annual and cumulative SEP 50001 program energy savings without revealing data or analysis that could lead to the identification of specific facilities.

US DOE may use data to study the effectiveness and impact of the SEP 50001 program. Results from such analysis will be made public only if participating organization anonymity can be ensured. The participating organization may be asked if they wish to voluntarily participate in the formation of case studies and other activities regarding the SEP 50001 program.

All data provided to US DOE is subject to the Freedom of Information Act (FOIA); however, US DOE will notify the SEP 50001-certified facility if a FOIA request has been submitted for which their data might be responsive. US DOE will consult with the SEP 50001-certified facility and ensure the facility has an opportunity to inform US DOE what data they view is proprietary. US DOE will review the SEP 50001-certified facility’s suggestions and will not release to the public any data US DOE deems proprietary.

Individual SEP 50001 Verification Bodies have established and implemented procedures for ensuring confidentiality. These procedures address both the SEP 50001 Verification Body as well as the individual auditor/verifier. Subcontracted or outsourced activities are subject to the same requirements.

1 Previous versions of the SEP program have specific application forms, which are available until 10 January 2020. As of 6 December 2020, all previous versions of the SEP Program will no longer be valid.

2 The number of EnMS-effective personnel (those who are actively contributing to fulfilling EnMS requirements) is used by the applicant’s SEP 50001 Verification Body to determine the number of audit days. The following worksheet may be used to determine effective personnel: https://betterbuildingssolutioncenter.energy.gov/iso-50001/sep-50001/sep-50001-application-enms-effective-personnel-guidance. The worksheet is consistent with the standard ISO 50003 Energy management systems -- Requirements for bodies providing audit and certification of energy management systems

3 Visit the SEP 50001 web site for a list of approved Verification Bodies:
[https://betterbuildingssolutioncenter.energy.gov/verification-bodies]

4 This information is used per ISO 50003 by SEP 50001 Verification Bodies to help determine the number of audit days.

5 Facility staff that spends 50 percent or greater time on energy management.

In this document, "SEP 50001" refers to the SEP 50001 (2019) version of the program.

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