5900-436 Indoor Environmental Quality Measurement Form for E

OMB Control No. 2060-0347

Appendix A: Indoor Environmental Quality Measurement form for ENERGY STAR
Building Verification Site Visit
Instructions: The LP (or their representative) must use this form to record measurements taken during the ENERGY
STAR building verification site visit. Forms should be kept on file for two years. Should an ENERGY STAR application
be selected for an audit, you will be required to submit this form as supporting documentation. Please attach
additional notes pages if necessary.
Property Name: _______________________________________________________________________
Property Address: _____________________________________________________________________
LP Name: _______________________________________________ Site visit date: ________________
Information on person conducting the site visit:
Name: ____________________

Title: ____________________ Organization: __________________

Outdoor Air Ventilation
The LP must verify that the property meets the minimum ventilation rates according to ANSI/ASHRAE Standard 62.1,
Ventilation for Acceptable Indoor Air Quality.
Select the method used (check all that apply)
� For mechanically ventilated buildings, the LP must confirm minimum outdoor ventilation rates by any of the following;
� direct airflow measurements per ANSI/ASHRAE Standard 62.1, Section 6.2, the Ventilation Rate Procedure, or
� CO2 concentration measurements per ASHRAE 62.1 Appendix C, and ASTM D6245 Standard Guide for Using
Indoor CO2 Concentrations to Evaluate Indoor Air Quality and Ventilation, or
� detailed airflow calculations derived from as-built equipment specifications, and physical inspection of system
operation and control
� For naturally ventilated buildings, the LP must follow ASHRAE 62.1, Section 6.4, Natural Ventilation Procedure to
confirm the minimum outdoor air opening and space configuration requirements.
� Dwelling units in multifamily housing shall use ASHRAE 62.2, Ventilation and Acceptable Indoor Air Quality in
Residential Buildings. Hospitals and Senior Care Communities may use ASHRAE Standard 62.1, or ANSI/ASHRAE/ASHE
Standard 170: Ventilation of Health Care Facilities - 2013.
� For building occupancy types not covered by these standards, buildings with physical constraints that make it
infeasible to provide these minimum outdoor air rates, as well as spaces that are inaccessible to the LP (e.g. individual
apartments) the LP must use their professional judgement to confirm that outdoor air ventilation has not been
compromised in pursuit of energy conservation.
Description of verification method and documentation of measurement results:

^ĞƉƚĞŵďĞƌ 2018
EPA Form 5900-436

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OMB Control No. 2060-0347

Property Name: ________________________________________________________________________

Thermal Environmental Conditions
The LP must verify that the property meets the acceptable thermal environmental conditions according ANSI/
ASHRAE Standard 55, Thermal Environmental Conditions for Human Occupancy. dĞŵƉĞƌĂƚƵƌĞŵĞĂƐƵƌĞŵĞŶƚƐĂƌĞŶŽƚ
ƌĞƋƵŝƌĞĚĨŽƌĂƚĂĞŶƚĞƌƐ͘
Location

Space
Function

^ĞƉƚĞŵďĞƌ2018
EPA Form 5900-436

Date
and
Time

Specific
>ocation

Dry
Relative Air Speed
bulb Humidity (ft/min)
Temp.
(%)
(optional)
(°F)

Notes and Observations

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OMB Control No. 2060-0347

Property Name: ____________________________________________________________________

Indoor Lighting Conditions
The LP must verify that the property meets the acceptable minimum illumination levels as recommended by
the Illuminating Engineering Society of North America (IESNA) Lighting Handbook. ,ŽƌŝnjŽŶƚĂůĂŶĚͬŽƌǀĞƌƚŝĐĂů
ŝůůƵŵŝŶĂƚŝŽŶŵĞĂƐƵƌĞŵĞŶƚƐŵƵƐƚďĞƚĂŬĞŶ͘ŽƚŚŵĞĂƐƵƌĞŵĞŶƚƐĂƌĞŶŽƚƌĞƋƵŝƌĞĚ͘
Location

Space
Function

Date
and
Time

Specific
Location

Horizontal
Illumination
(fc)

Vertical
Illumination
(fc)

Notes and Observations

I verify that the measurements on this form are accurate and taken in accordance with the requirements described in
the ENERGY STAR Licensed Professional’s Guide.

LP Signature: ______________________________________________________
^ĞƉƚĞŵďĞƌ2018
EPA Form 5900-436

Date: _____________
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OMB Control No. 2060-0347
Property Name: ____________________________________________________________________

Notes Section (optional)
Please use this section to document your notes about the site visit.

September 2018
EPA Form 5900-436

Page 4 of 4

The public reporting and recordkeeping burden for this collection of information is estimated to average 15
minutes per response. Send comments on the Agency's need for this information, the accuracy of the
provided burden estimates, and any suggested methods for minimizing respondent burden, including
through the use of automated collection techniques to the Director, Collection Strategies Division, U.S.
Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460.
Include the OMB control number in any correspondence. Do not send the completed form to this address.