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Name ____________________________Address_______________________________ Date ____________ Drawing ______ Time___________ Facing ______ Precipitation

Base ___________ Ceiling Height _______ Volume ______________

1st Flr ___________ Ceiling Height _______ Volume ______________

2nd Flr ___________ Ceiling Height _______ Volume ______________

Other ___________ Ceiling Height _______ Volume ______________

Other ___________ Ceiling Height _______ Volume ______________

Cloudy

Total _______________

Volume ______________

63

Sunny

80

N

Home Performance Assessment Customer Interview Questions
1. Tell us about your home. a. When was this home built? b. How long have you lived here? c. What type of heating system do you have? i. Fuel type? ii. How old is the heating system? iii. When was the last time it was serviced/cleaned and tuned? iv. Do you regularly change your furnace filter? (if forced-air furnace) v. When was the last time you changed your furnace’s filter? (if forced-air furnace) d. Do you have a working fireplace? i. How often do you use it? ii. How often is the flue cleaned? e. Thermostat type & location? f. Do you have access to your past year’s utility bills? i. Will you supply these bills so we can properly calculate potential savings of retrofit measures? 2. Tell us how you use your appliances. a. Do you use other appliances for comfort heating? i. What type? ii. Fuel type? iii. Location in the house? b. Do you ever use the oven to supplement your heating system? c. How often do you use your oven? (% of meals) 3. Tell us about any problems you are having in your home. a. Does your home have cold rooms or areas? i. Where and when does this occur? b. Does your home have rooms or areas that are too warm? i. Where and when does this occur? c. Are there drafty areas in your home? i. Where and when does this occur? d. Do you close off any rooms to prevent heating them? e. Is there a known moisture or condensation problem in the home? i. In what area(s) of the home? f. Is there any known mold issue in your home? g. Does the basement get wet at any time during the year? h. Does ice form on the eaves or in the attic during the winter? i. Does your roof leak during any time of the year? j. Do any occupants suffer from headaches, flu, or nausea during the heating system?

# of units 2-4 Age of Home Utility Information Electric Provider Copy of 1 year of bills? Heating Fuel Provider Copy of 1 year of bills? PEPCO NOVA BGE DE Date Completion Time NJ Home Phone Cell Phone Work Phone Townhouse Interior Unit 5+ Apartment Mobile Home # of Occupants Account # Yes Yes No Account # No Household Systems & Appliance Information Heating System Fuel Natural Gas Electricity Backup Electric Heat? Yes No Central A/C Unit? Yes No DHW Fuel Natural Gas Electricity Primary Cooking Fuel Natural Gas Electricity Oven/Range Use <25% 25-33% Dryer Fuel Natural Gas Electricity Customer Interview Notes Oil Propane Oil Propane 33-50% Propane Propane 50-75% 75+% .Home Performance Assessment Data Collection Form Program Building Analyst Arrival Time Customer Information Customer Name Street Address City. State & Zip Email Address General House Information House Type Single-family If townhouse End Unit If apartment.

Home Performance Assessment Data Collection Form Exterior Inspection Exterior Temp (F) Exterior CO level Weather Conditions # of Stories Orientation Shielding Normal Exposed Well-shielded Drainage Concerns? Yes No Repair Exterior Siding. Trim or Flashing? Yes Roof Condition Good Poor Flashing Issues? Yes No Durability Concerns? Yes No # of Exhaust Pipes Exterior Inspection Notes N NE E SE S SW W NW No Cooling System # of Systems System 1 System Capacity Install Date System 2 System Capacity Install Date Cooling System(s) Notes Description tons (Manufacturer & model #) % of Load Handled (100% if only 1) Description tons (Manufacturer & model #) % of Load Handled . Fascia.

Home Performance Assessment Data Collection Form Interior Inspection Interior Temp (F) Foundation Type Windows # of Windows Total # of Windows Type of Windows Window Features Window Frame Type Storm Windows? Avg Height (in) Window Notes Basement Slab Closed Crawlspace Open Crawlspace East Side South Side Single-pane Tinted Wood Yes West Side North Side % of Windows Facing Sun Double-pane Triple-pane Reflective Low-e Vinyl Metal No Avg Width (in) Quadruple-pane Glass Doors # of Glass Doors Total # of Glass Doors Type of Glass Doors Glass Door Features Storm Doors? Avg Height (in) Glass Door Notes East Side South Side Single-pane Tinted Yes West Side North Side % of Glass Doors Facing Sun Double-pane Triple-pane Reflective Low-e No Avg Width (in) Quadruple-pane .

Home Performance Assessment Data Collection Form Exterior Doors # of Exterior Doors Type of Doors Storm Doors? Exterior Door Notes Insulated Yes Solid Wood No Wood Panel Exterior Walls # of Exterior Walls Exterior Wall 1 % of Total Wall Area Insulation Condition Exterior Wall 2 % of Total Wall Area Insulation Condition Exterior Wall 3 % of Total Wall Area Insulation Condition Exterior Wall 4 % of Total Wall Area Insulation Condition Exterior Wall Notes Description None Description None Description None Description None Poor Cavity Depth (in) Moderate Well-insulated Poor Cavity Depth (in) Moderate Well-insulated Poor Cavity Depth (in) Moderate Well-insulated Poor Cavity Depth (in) Moderate Well-insulated .

Home Performance Assessment Data Collection Form Cantilevers. Ceilings Over Garages & Open Crawlspaces Section 1 Type Length (ft) Insulation Depth (in) Insulation Condition Section 1 Notes Description Cantilever Ceiling Over Garage Width (ft) Poor Moderate Open Crawlspace Area (ft2) Well-Insulated None Section 2 Type Length (ft) Insulation Depth (in) Insulation Condition Section 2 Notes Description Cantilever Ceiling Over Garage Width (ft) Poor Moderate Open Crawlspace Area (ft2) Well-Insulated None Section 3 Type Length (ft) Insulation Depth (in) Insulation Condition Section 3 Notes Description Cantilever Ceiling Over Garage Width (ft) Poor Moderate Open Crawlspace Area (ft2) Well-Insulated None .

Home Performance Assessment Data Collection Form Attic # of Attic Areas Attic Area 1 Length (ft) Insulation Type Installation Type Insulation Depth (in) Insulation Condition Recessed Lights to Seal Exhaust Fans to Install Attic 1 Notes Description Cellulose Dense Pack None Width (ft) Fiberglass Loose Fill Foam Batts Area (ft2) Mineral Wool High Density Well-insulated Vermiculite Low Density Poor Moderate Attic Hatches to Seal Exhausts to Insulate/Vent Attic Area 2 Length (ft) Insulation Type Installation Type Insulation Depth (in) Insulation Condition Recessed Lights to Seal Exhaust Fans to Install Attic 2 Notes Description Cellulose Dense Pack None Width (ft) Fiberglass Loose Fill Foam Batts Area (ft2) Mineral Wool High Density Well-insulated Vermiculite Low Density Poor Moderate Attic Hatches to Seal Exhausts to Insulate/Vent .

Home Performance Assessment Data Collection Form Kneewalls & Vertical Attic Walls Wall 1 Wall Width (ft) Insulation Depth (in) Insulation Condition Wall 1 Notes Description Wall Length (ft) None Poor Moderate Well-insulated Wall 2 Wall Width (ft) Insulation Depth (in) Insulation Condition Wall 2 Notes Description Wall Length (ft) None Poor Moderate Well-insulated Wall 3 Wall Width (ft) Insulation Depth (in) Insulation Condition Wall 3 Notes Description Wall Length (ft) None Poor Moderate Well-insulated .

Home Performance Assessment Data Collection Form Duct System Duct System Location Attic Conditioned Space Exterior Wall Garage Unconditioned Basement/Crawl No R-Value of Duct Insulation In Slab % of Ducts in Unconditioned Space Ducts Insulated? Yes Duct System Notes Basement & Enclosed Crawlspaces # of Sections Section 1 % of Foundation Area Insulation Depth (in) Insulation Condition Section 1 Notes Description Ceiling Height (ft) None Poor Moderate Well-insulated Section 2 % of Foundation Area Insulation Depth (in) Insulation Condition Section 2 Notes Description Ceiling Height (ft) None Poor Moderate Well-insulated .

Home Performance Assessment Data Collection Form Rim Joist & Band Joist # of Joists Joist 1 Joist Length (ft) Insulation Condition Joist 1 Notes Description None Insulation Depth (in) Poor Moderate Well-insulated Joist 2 Joist Length (ft) Insulation Condition Joist 2 Notes Description None Insulation Depth (in) Poor Moderate Well-insulated .

Home Performance Assessment Data Collection Form Lighting Replacement CFLs Standard Base Indoor Flood Outdoor Flood 3-Way Globe Candelabra Other ______________ Water Conservation Replacement Devices Low-Flow Showerhead Kitchen Aerator Bathroom Aerator Appliances Age Washer Dryer Dehumidifer Dishwasher Refrigerator 1 Refrigerator 2 Freezer Characteristics (circle one for each row) Standard Compact Standard Standard Small Chest High Capacity Compact Medium Upright Freezer? Quantity (tally) Flow Quantity (tally) Preferred Wattage(s) Large Yes No Lighting. Water Conservation & Appliance Notes .

Home Performance Assessment Data Collection Form Diagnostics Oven CO Testing # of Ovens Oven 1 CO Level Oven 2 CO Level Ambient CO Testing # of Areas Tested Area 1 CO Level Area 2 CO Level CO Notes Description ppm Description ppm 1 2 Description ppm Description ppm .

Home Performance Assessment Data Collection Form Combustion Appliance Zone (CAZ) Testing # of CAZs CAZ 1 Description Venting Type (check one) Isolated CAZ Orphan nat draft DHW Nat draft boiler/furn w/ DHW Nat draft boiler/furn w/ DHW & damper Individual nat draft boiler/furn Mech assisted boiler/furn w/ DHW Mech assisted boiler/furn & DHW alone Exhaust chimey-top draft inducer fan Hi static press flame retention-head oil Sealed combustion CAZ 1 Notes Ambient CO Level # of Gas Leaks Tagged Baseline Pressure Worst Case Pressure Adjusted Worst Case Adjusted = Baseline .Worst Case ppm Pa Pa Pa CAZ 2 Description Venting Type (check one) Isolated CAZ Orphan nat draft DHW Nat draft boiler/furn w/ DHW Nat draft boiler/furn w/ DHW & damper Individual nat draft boiler/furn Mech assisted boiler/furn w/ DHW Mech assisted boiler/furn & DHW alone Exhaust chimey-top draft inducer fan Hi static press flame retention-head oil Sealed combustion CAZ 2 Notes Ambient CO Level # of Gas Leaks Tagged Baseline Pressure Worst Case Pressure Adjusted Worst Case Adjusted = Baseline .Worst Case ppm Pa Pa Pa .

Home Performance Assessment Data Collection Form Domestic Hot Water (DHW) # of DHW Systems System 1 % of Load Served Efficiency Temp Setpoint Description (100% if only 1 system) Regular High Venting Type (check one) Electric. indirect tank or tankless coil Isolated CAZ Atmospheric .individual appliance Fan-assisted or induced draft B-vent Direct-vent or power-vented Worst Case Conditions Spillage Test # of Seconds Draft CO Level Pass Fail Pa ppm Natural Conditions (if failed under worst) Spillage Test Pass Fail # of Seconds Draft Pa CO Level ppm System 1 Notes .

Home Performance Assessment Data Collection Form System 2 % of Load Served Efficiency Temp Setpoint Description Regular High Venting Type (check one) Electric. indirect tank or tankless coil Isolated CAZ Atmospheric .individual appliance Fan-assisted or induced draft B-vent Direct-vent or power-vented Worst Case Conditions Spillage Test # of Seconds Draft CO Level Pass Fail Pa ppm Natural Conditions (if failed under worst) Spillage Test Pass Fail # of Seconds Draft Pa CO Level ppm System 2 Notes .

common vent Fan-assisted or induced draft B-vent Direct-vent or power-vented Sealed combustion Worst Case Conditions Spillage Test # of Seconds Draft CO Level System 1 Notes Distribution System Type Ducts Hydronic Capacity Efficiency % of Load Served (100% if only 1 system) Baseboards kBTU/h % Pass Fail Pa ppm Natural Conditions (if failed under worst) Spillage Test Pass Fail # of Seconds Draft Pa CO Level ppm .Home Performance Assessment Data Collection Form Heating Sytem # of Systems System 1 Description Venting Type (check one) Electric Isolated CAZ Atmospheric .individual appliance Atmospheric .

Home Performance Assessment Data Collection Form System 2 Description Distribution System Type Ducts Hydronic Capacity Efficiency % of Load Served Venting Type (check one) Electric Isolated CAZ Atmospheric .common vent Fan-assisted or induced draft B-vent Direct-vent or power-vented Sealed combustion Worst Case Conditions Spillage Test # of Seconds Draft CO Level System 2 Notes Baseboards kBTU/h % Pass Fail Pa ppm Natural Conditions (if failed under worst) Spillage Test Pass Fail # of Seconds Draft Pa CO Level ppm Duct Leakage Test Duct Leakage (in house) Duct Leakage (to outside) Duct Notes CFM25 CFM25 .individual appliance Atmospheric .

Home Performance Assessment Data Collection Form Air Leakage Test Volume of Home N Factor Minimum BAS Tested BAS Calculations Airflow = 0.35 X Volume/60 Minimum BAS = Airflow * N ft3 CFM50 CFM50 Stories 1 1.4 to 100% CFM50 Air Leakage Notes .2 14.5 2 2.8 16.2 15.5 3 BAS Range 70% N Factor 20 17.

Home Performance Assessment Data Collection Form Utility Consumption Data Electricity Units Fuel Price/Rate ($) Year of Recent Bills kWh Most Recent Month Monthly Consumption (kWh) Most Recent Month Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Natural Gas Units Fuel Price/Rate ($) Year of Recent Bills Therms CCF Most Recent Month Monthly Consumption (Therms or CCF) Most Recent Month Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 .