gms data collection form
TRANSCRIPT
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Name ____________________________Address_______________________________ Date ____________ Drawing ____
___________
g
g
_______
______________
1stFlr
___________
CeilingH
eight_______
Volume______________
2ndFlr___________
CeilingH
eight_______
Volume______________
Other
___________
CeilingH
eight_______
Volume______________
Other
___________
CeilingH
eight_______
Volume______________
Total
_______________
Volume______________
N
Time___________ Facing ____
Sunny Cloudy Precipitati
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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 furnaces 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 years utility bills?
i. Will you supply these bills so we can properly calculate potential savings ofretrofit 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?
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Home Performance Assessment Data Collection Form
Program PEPCO NOVA BGE DE NJ
Building Analyst Date
Arrival Time Completion Time
Customer Information
Customer Name Home Phone
Street Address Cell Phone
City, State & Zip Work Phone
Email Address
General House Information
House Type Single-family Townhouse Apartment Mobile Home
If townhouse End Unit Interior Unit
If apartment, # of units 2-4 5+
Age of Home # of Occupants
Utility Information
Electric Provider Account #
Copy of 1 year of bills? Yes No
Heating Fuel Provider Account #
Copy of 1 year of bills? Yes No
Household Systems & Appliance Information
Heating System Fuel Natural Gas Electricity Oil Propane
Backup Electric Heat? Yes No
Central A/C Unit? Yes No
DHW Fuel Natural Gas Electricity Oil Propane
Primary Cooking Fuel Natural Gas Electricity Propane
Oven/Range Use
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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, Fascia, Trim or Flashing? Yes No
Roof Condition Good Poor
Flashing Issues? Yes No
Durability Concerns? Yes No
# of Exhaust Pipes
Exterior Inspection Notes
Cooling System
# of Systems
System 1 Description
System Capacity tons (Manufacturer & model #)
Install Date % of Load Handled (100% if only 1)
System 2 Description
System Capacity tons (Manufacturer & model #)
Install Date % of Load Handled
Cooling System(s) Notes
N NE E SE S SW W NW
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Home Performance Assessment Data Collection Form
Interior Inspection
Interior Temp (F)
Foundation Type Basement Slab Open Crawlspace
Windows
# of Windows East Side West Side
South Side North Side
Total # of Windows % of Windows Facing Sun
Type of Windows Single-pane Double-pane Triple-pane
Window Features Tinted Reflective Low-e
Window Frame Type Wood Vinyl Metal
Storm Windows? Yes No
Avg Height (in) Avg Width (in)
Window Notes
Glass Doors
# of Glass Doors East Side West Side
South Side North Side
Total # of Glass Doors % of Glass Doors Facing Sun
Type of Glass Doors Single-pane Double-pane Triple-pane
Glass Door Features Tinted Reflective Low-e
Storm Doors? Yes No
Avg Height (in) Avg Width (in)
Glass Door Notes
Closed Crawlspace
Quadruple-pane
Quadruple-pane
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Home Performance Assessment Data Collection Form
Exterior Doors
# of Exterior Doors
Type of Doors Insulated Solid Wood Wood Panel
Storm Doors? Yes No
Exterior Door Notes
Exterior Walls
# of Exterior Walls
Exterior Wall 1 Description
% of Total Wall Area Cavity Depth (in)
Insulation Condition None Poor Moderate Well-insulated
Exterior Wall 2 Description
% of Total Wall Area Cavity Depth (in)
Insulation Condition None Poor Moderate Well-insulated
Exterior Wall 3 Description
% of Total Wall Area Cavity Depth (in)
Insulation Condition None Poor Moderate Well-insulated
Exterior Wall 4 Description
% of Total Wall Area Cavity Depth (in)
Insulation Condition None Poor Moderate Well-insulated
Exterior Wall Notes
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Home Performance Assessment Data Collection Form
Cantilevers, Ceilings Over Garages & Open Crawlspaces
Section 1 Description
Type Cantilever
Length (ft) Width (ft) Area (ft2)
Insulation Depth (in)
Insulation Condition None Poor Moderate Well-Insulated
Section 1 Notes
Section 2 Description
Type Cantilever
Length (ft) Width (ft) Area (ft2)
Insulation Depth (in)
Insulation Condition None Poor Moderate Well-Insulated
Section 2 Notes
Section 3 Description
Type Cantilever
Length (ft) Width (ft) Area (ft2)
Insulation Depth (in)Insulation Condition None Poor Moderate Well-Insulated
Section 3 Notes
Ceiling Over Garage
Ceiling Over Garage
Open Crawlspace
Open Crawlspace
Ceiling Over Garage Open Crawlspace
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Attic
# of Attic Areas
Attic Area 1 Description
Length (ft) Width (ft) Area (ft2)
Insulation Type Cellulose Fiberglass Foam Mineral Wool Vermiculite
Installation Type Dense Pack Loose Fill Batts High Density Low Density
Insulation Depth (in)
Insulation Condition None Poor Moderate Well-insulated
Recessed Lights to Seal Attic Hatches to Seal
Exhaust Fans to Install Exhausts to Insulate/Vent
Attic 1 Notes
Attic Area 2 Description
Length (ft) Width (ft) Area (ft2)
Insulation Type Cellulose Fiberglass Foam Mineral Wool Vermiculite
Installation Type Dense Pack Loose Fill Batts High Density Low Density
Insulation Depth (in)
Insulation Condition None Poor Moderate Well-insulated
Recessed Lights to Seal Attic Hatches to Seal
Exhaust Fans to Install Exhausts to Insulate/Vent
Attic 2 Notes
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Home Performance Assessment Data Collection Form
Kneewalls & Vertical Attic Walls
Wall 1 Description
Wall Width (ft) Wall Length (ft)
Insulation Depth (in)
Insulation Condition None Poor Moderate Well-insulated
Wall 1 Notes
Wall 2 Description
Wall Width (ft) Wall Length (ft)
Insulation Depth (in)
Insulation Condition None Poor Moderate Well-insulated
Wall 2 Notes
Wall 3 Description
Wall Width (ft) Wall Length (ft)
Insulation Depth (in)
Insulation Condition None Poor Moderate Well-insulated
Wall 3 Notes
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Home Performance Assessment Data Collection Form
Duct System
Duct System Location Attic Exterior Wall In Slab
Garage
% of Ducts in Unconditioned Space
Ducts Insulated? Yes No R-Value of Duct Insulation
Duct System Notes
Basement & Enclosed Crawlspaces
# of Sections
Section 1 Description
% of Foundation Area Ceiling Height (ft)Insulation Depth (in)
Insulation Condition None Poor Moderate Well-insulated
Section 1 Notes
Section 2 Description
% of Foundation Area Ceiling Height (ft)Insulation Depth (in)
Insulation Condition None Poor Moderate Well-insulated
Section 2 Notes
Conditioned Space
Unconditioned Basement/Crawl
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Rim Joist & Band Joist
# of Joists
Joist 1 Description
Joist Length (ft) Insulation Depth (in)
Insulation Condition None Poor Moderate Well-insulated
Joist 1 Notes
Joist 2 Description
Joist Length (ft) Insulation Depth (in)
Insulation Condition None Poor Moderate Well-insulated
Joist 2 Notes
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Home Performance Assessment Data Collection Form
Lighting
Replacement CFLs
Standard Base
Indoor Flood
Outdoor Flood
3-Way
Globe
Candelabra
Other ______________
Water Conservation
Replacement Devices Flow
Low-Flow Showerhead
Kitchen Aerator
Bathroom Aerator
Appliances
Age Freezer?
Washer Standard CompactDryer
Dehumidifer Standard High Capacity
Dishwasher Standard Compact
Refrigerator 1 Small Medium Large Yes No
Refrigerator 2
Freezer Chest Upright
Lighting, Water Conservation & Appliance Notes
Quantity (tally) Preferred Wattage(s)
Quantity (tally)
Characteristics (circle one for each row)
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Home Performance Assessment Data Collection Form
Diagnostics
Oven CO Testing
# of Ovens
Oven 1 Description
CO Level ppm
Oven 2 Description
CO Level ppm
Ambient CO Testing
# of Areas Tested 1 2
Area 1 Description
CO Level ppm
Area 2 Description
CO Level ppm
CO Notes
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Home Performance Assessment Data Collection Form
Combustion Appliance Zone (CAZ) Testing
# of CAZs
CAZ 1 Description
Isolated CAZ Ambient CO Level ppm
Orphan nat draft DHW # of Gas Leaks Tagged
Nat draft boiler/furn w/ DHW
Nat draft boiler/furn w/ DHW & damper Baseline Pressure Pa
Individual nat draft boiler/furn Worst Case Pressure Pa
Mech assisted boiler/furn w/ DHW Adjusted Worst Case Pa
Mech assisted boiler/furn & DHW alone
Exhaust chimey-top draft inducer fan Adjusted = Baseline - Worst Case
Hi static press flame retention-head oil
Sealed combustion
CAZ 1 Notes
CAZ 2 Description
Isolated CAZ Ambient CO Level ppm
Orphan nat draft DHW # of Gas Leaks Tagged
Nat draft boiler/furn w/ DHW
Nat draft boiler/furn w/ DHW & damper Baseline Pressure Pa
Individual nat draft boiler/furn Worst Case Pressure Pa
Mech assisted boiler/furn w/ DHW Adjusted Worst Case Pa
Mech assisted boiler/furn & DHW alone
Exhaust chimey-top draft inducer fan Adjusted = Baseline - Worst CaseHi static press flame retention-head oil
Sealed combustion
CAZ 2 Notes
Venting Type (check one)
Venting Type (check one)
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Domestic Hot Water (DHW)
# of DHW Systems
System 1 Description
% of Load Served (100% if only 1 system)
Efficiency Regular High
Temp Setpoint
Worst Case Conditions
Electric, indirect tank or tankless coil Spillage Test Pass Fail
Isolated CAZ # of Seconds
Atmospheric - individual appliance Draft Pa
Fan-assisted or induced draft CO Level ppm
B-vent
Direct-vent or power-vented Natural Conditions (if failed under worst)
Spillage Test Pass Fail
# of Seconds
Draft Pa
CO Level ppm
System 1 Notes
Venting Type (check one)
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Home Performance Assessment Data Collection Form
System 2 Description
% of Load Served
Efficiency Regular High
Temp Setpoint
Worst Case Conditions
Electric, indirect tank or tankless coil Spillage Test Pass Fail
Isolated CAZ # of Seconds
Atmospheric - individual appliance Draft Pa
Fan-assisted or induced draft CO Level ppm
B-vent
Direct-vent or power-vented Natural Conditions (if failed under worst)
Spillage Test Pass Fail
# of Seconds
Draft Pa
CO Level ppm
System 2 Notes
Venting Type (check one)
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Heating Sytem
# of Systems
System 1 Description
Distribution System Type
Electric Ducts Hydronic
Isolated CAZ
Atmospheric - individual appliance Capacity kBTU/h
Atmospheric - common vent Efficiency %
Fan-assisted or induced draft % of Load Served
B-vent (100% if only 1 system)
Direct-vent or power-vented
Sealed combustion
Worst Case Conditions Natural Conditions (if failed under worst)
Spillage Test Pass Fail Spillage Test Pass Fail
# of Seconds # of Seconds
Draft Pa Draft Pa
CO Level ppm CO Level ppm
System 1 Notes
Baseboards
Venting Type (check one)
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Home Performance Assessment Data Collection Form
System 2 Description
Distribution System Type
Electric Ducts Hydronic
Isolated CAZ
Atmospheric - individual appliance Capacity kBTU/h
Atmospheric - common vent Efficiency %
Fan-assisted or induced draft % of Load Served
B-vent
Direct-vent or power-vented
Sealed combustion
Worst Case Conditions Natural Conditions (if failed under worst)
Spillage Test Pass Fail Spillage Test Pass Fail
# of Seconds # of Seconds
Draft Pa Draft Pa
CO Level ppm CO Level ppm
System 2 Notes
Duct Leakage Test
Duct Leakage (in house) CFM25
Duct Leakage (to outside) CFM25
Duct Notes
Venting Type (check one)
Baseboards
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Air Leakage Test
Volume of Home ft3
N Factor
Minimum BAS CFM50
Tested BAS CFM50 BAS Range to CFM50
70% 100%
Calculations Stories N Factor
Airflow = 0.35 X Volume/60 1 20
Minimum BAS = Airflow * N 1.5 17.8
2 16.2
2.5 15.2
3 14.4
Air Leakage Notes
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Home Performance Assessment Data Collection Form
Utility Consumption Data
Electricity
Units kWh
Fuel Price/Rate ($)
Year of Recent Bills Most Recent Month
Monthly Consumption (kWh)
Most Recent Month
Month 2
Month 3
Month 4
Month 5
Month 6
Month 7
Month 8
Month 9
Month 10
Month 11
Month 12
Natural Gas
Units Therms CCF
Fuel Price/Rate ($)
Year of Recent Bills Most Recent Month
Monthly Consumption (Therms or CCF)
Most Recent Month
Month 2
Month 3
Month 4Month 5
Month 6
Month 7
Month 8
Month 9
Month 10
Month 11
Month 12