gms data collection form

8/8/2019 GMS Data Collection Form

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63

80

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


2/20

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


4/20


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 Capacity tons (Manufacturer & model #)

Install Date % of Load Handled

Cooling System(s) Notes

N NE E SE S SW W NW


5/20


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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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 Notes


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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


Type Cantilever



Insulation Condition None Poor Moderate Well-Insulated

Section 2 Notes


Type Cantilever


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


8/20


Attic

# of Attic Areas

Attic Area 1 Description


Insulation Type Cellulose Fiberglass Foam Mineral Wool Vermiculite

Installation Type Dense Pack Loose Fill Batts High Density Low Density



Recessed Lights to Seal Attic Hatches to Seal

Exhaust Fans to Install Exhausts to Insulate/Vent

Attic 1 Notes

Attic Area 2 Description


Insulation Type Cellulose Fiberglass Foam Mineral Wool Vermiculite

Installation Type Dense Pack Loose Fill Batts High Density Low Density



Recessed Lights to Seal Attic Hatches to Seal

Exhaust Fans to Install Exhausts to Insulate/Vent

Attic 2 Notes


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Kneewalls & Vertical Attic Walls

Wall 1 Description

Wall Width (ft) Wall Length (ft)



Wall 1 Notes

Wall 2 Description




Wall 2 Notes

Wall 3 Description




Wall 3 Notes


10/20


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


% of Foundation Area Ceiling Height (ft)Insulation Depth (in)


Section 1 Notes


% of Foundation Area Ceiling Height (ft)Insulation Depth (in)


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)


Joist 1 Notes

Joist 2 Description

Joist Length (ft) Insulation Depth (in)


Joist 2 Notes


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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)


13/20


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


14/20


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)



15/20


Domestic Hot Water (DHW)

# of DHW Systems


% 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



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% 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



17/20


Heating Sytem

# of Systems


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



18/20



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


Baseboards


19/20


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


20/20


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

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