AUDIT DATA COLLECTION FORM

Client Name:

HH#

Address:

MPLS, MN

Phone 1:

Phone 2:

Audit Date:

Auditor:

Temp In: Out:

Dwelling characteristics

Year Built:

# Conditioned Stories:

Total square feet:

Comments:

1. Year Dwelling Constructed

2. Any remodeling? Where? What year?

3. # people living in home?

4. Daytime Tstat setting?

5. Nighttime Tstat setting?

6. Existing setback?

7. Setback properly used?

8. Client comfort, list cold room, warm rooms, etc.

9. Supply/returns in cold rooms?

10. Basement used as living space?

11. Basement temp during winter?

12. Attic use: Living, storage, etc.

13. Will attic use affect insulation?

14. Rooms closed off during winter?

15. Age of furnace/boiler?

16. Describe repairs in last 3 years.

17. Routine maintenance? Yes/no

18. Describe routine maintenance.

19. Do you change filters? How often?

20. How old is your water tank?

21. Routine maintenance? Yes/no

22. Icicles or ice dams in winter? Explain.

23. Water in basement/crawlspace?

24. Evidence of moisture/mold?

25. Freezing pipes?

26. Recurring headaches, itching/burning eyes?

27. Roof leaks?

28. Plans for remodeling?

29. Homeschooled children? Daycare?

30. Crawlspace used for storage?

31. Other problems?

32. Area of most concern that could possibly be addressed?

Building Shell-Walls

Wall Type 1

Wall Type:

|_| Balloon

|_| Platform

|_| Masonry

|_| Block

|_| Other

Stud Size:

|_| 2x2

|_| 2x3

|_| 2x4

|_| 2x6

|_| 2x8

Exterior Type:

|_| Wood

|_| Metal/Vinyl

|_| Stucco

|_| Brick/Stone

|_| Other

Exposed to:

|_| Outside

|_| Buffered

Existing R-Value:

Existing Insul:

|_| Cell Blown

|_| FG Blown

|_| Rockwool

|_| Batts FG

|_| Polystyrene

|_| Other

Wall Codes & Area (break out 1st and 2nd fl):

Added Insulation:

|_| Blown cellulose

|_| Cellulose-interior

|_| Cellulose-wood

|_| Cellulose-slate/vinyl

|_| Cellulose-steel/alum

|_| Cellulose-stucco

Additional Costs (i.e. LSWP):

North

East

South

West

Comments:

Wall Type 2

Wall Type:

|_| Balloon

|_| Platform

|_| Masonry

|_| Block

|_| Other

Stud Size:

|_| 2x2

|_| 2x3

|_| 2x4

|_| 2x6

|_| 2x8

Exterior Type:

|_| Wood

|_| Metal/Vinyl

|_| Stucco

|_| Brick/Stone

|_| Other

Exposed to:

|_| Outside

|_| Buffered

Existing R-Value:

Existing Insul:

|_| Cell Blown

|_| FG Blown

|_| Rockwool

|_| Batts FG

|_| Polystyrene

|_| Other

Wall Codes & Area (break out 1st and 2nd fl):

Added Insulation:

|_| Blown cellulose

|_| Cellulose-interior

|_| Cellulose-wood

|_| Cellulose-slate/vinyl

|_| Cellulose-steel/alum

|_| Cellulose-stucco

Additional Costs (i.e. LSWP):

North

East

South

West

Comments:

Building Shell-Attic

Attic 1

Attic Code:

Joist Spacing: |_| 16in |_| 24in

Area (sq ft):

Attic Type:

|_| Floored

|_| Unfloored

|_| Cathedral or Flat

|_| Outer Ceiling Joist

|_| Collar Beam

|_| Kneewall

|_| Roof Rafter

Existing Insulation:

|_| Cellulose Blown

|_| FG Blown

|_| Rockwool

|_| Batts FG

|_| Other:

Existing Depth (in):

Comments: (include information on bypasses, notable features, etc.)

Added Insulation

|_| Blown cellulose

|_| Below Floor-Cellulose

|_| Slants-Side Attic Method

|_| Slants-Drill/Blow/Patch

|_| FG Batt R22

|_| Other:

Additional Costs

|_| Access fee-Interior

|_| Access fee-Roof

|_| Bypass sealing: # hours ____

|_| Flue Shielding

|_| Vent Chutes: # chutes_____

|_| Hatch-horizontal

|_| Hatch-vertical

|_| Hatch-WS ONLY

|_| Knob & Tube

|_| Other:

Attic 2

Attic Code:

Joist Spacing: |_| 16in |_| 24in

Area (sq ft):

Attic Type:

|_| Floored

|_| Unfloored

|_| Cathedral or Flat

|_| Outer Ceiling Joist

|_| Collar Beam

|_| Kneewall

|_| Roof Rafter

Existing Insulation:

|_| Cellulose Blown

|_| FG Blown

|_| Rockwool

|_| Batts FG

|_| Other:

Existing Depth (in):

Comments: (include information on bypasses, notable features, etc.)

Added Insulation

|_| Blown cellulose

|_| Below Floor-Cellulose

|_| Slants-Side Attic Method

|_| Slants-Drill/Blow/Patch

|_| FG Batt R22

|_| Other:

Additional Costs

|_| Access fee-Interior

|_| Access fee-Roof

|_| Bypass sealing: # hours ____

|_| Flue Shielding

|_| Vent Chutes: # chutes_____

|_| Hatch-horizontal

|_| Hatch-vertical

|_| Hatch-WS ONLY

|_| Knob & Tube

|_| Other:

Attic 3

Attic Code:

Joist Spacing: |_| 16in |_| 24in

Area (sq ft):

Attic Type:

|_| Floored

|_| Unfloored

|_| Cathedral or Flat

|_| Outer Ceiling Joist

|_| Collar Beam

|_| Kneewall

|_| Roof Rafter

Existing Insulation:

|_| Cellulose Blown

|_| FG Blown

|_| Rockwool

|_| Batts FG

|_| Other:

Existing Depth (in):

Comments: (include information on bypasses, notable features, etc.)

Added Insulation

|_| Blown cellulose

|_| Below Floor-Cellulose

|_| Slants-Side Attic Method

|_| Slants-Drill/Blow/Patch

|_| FG Batt R22

|_| Other:

Additional Costs

|_| Access fee-Interior

|_| Access fee-Roof

|_| Bypass sealing: # hours ____

|_| Flue Shielding

|_| Vent Chutes: # chutes_____

|_| Hatch-horizontal

|_| Hatch-vertical

|_| Hatch-WS ONLY

|_| Knob & Tube

|_| Other:

Attic 4

Attic Code:

Joist Spacing: |_| 16in |_| 24in

Area (sq ft):

Attic Type:

|_| Floored

|_| Unfloored

|_| Cathedral or Flat

|_| Outer Ceiling Joist

|_| Collar Beam

|_| Kneewall

|_| Roof Rafter

Existing Insulation:

|_| Cellulose Blown

|_| FG Blown

|_| Rockwool

|_| Batts FG

|_| Other:

Existing Depth (in):

Comments: (include information on bypasses, notable features, etc.)

Added Insulation

|_| Blown cellulose

|_| Below Floor-Cellulose

|_| Slants-Side Attic Method

|_| Slants-Drill/Blow/Patch

|_| FG Batt R22

|_| Other:

Additional Costs

|_| Access fee-Interior

|_| Access fee-Roof

|_| Bypass sealing: # hours ____

|_| Flue Shielding

|_| Vent Chutes: # chutes_____

|_| Hatch-horizontal

|_| Hatch-vertical

|_| Hatch-WS ONLY

|_| Knob & Tube

|_| Other:

Building Shell-Foundation

Foundation 1

Foundation Code:

Type:

|_| Conditioned

|_| Non Conditioned

|_| Vented Non Conditioned

|_| Unintentionally Conditioned

|_| Slab Uninsulated

|_| Insulated Slab

Floor Area:

Joist size (in):

|_| 4 |_| 6 |_|8 |_| 10 |_| 12

Wall Height:

Total Perimeter:

Height Exposed:

Existing R-Value (walls):

Add Sill Insulation

|_| 2 Part Foam

|_| Rigid Board

Perimeter to Insulate:

Add Wall Insulation

|_| 2 Part Foam

|_| Rigid Board

Total sq ft:

|_| Vapor Barrier Needed

Total sq ft (include walls):

|_| Seal ducts in crawlspace

Comments:

Foundation 2

Foundation Code:

Type:

|_| Conditioned

|_| Non Conditioned

|_| Vented Non Conditioned

|_| Unintentionally Conditioned

|_| Slab Uninsulated

|_| Insulated Slab

Floor Area:

Joist size (in):

|_| 4 |_| 6 |_|8 |_| 10 |_| 12

Wall Height:

Total Perimeter:

Height Exposed:

Existing R-Value (walls):

Add Sill Insulation

|_| 2 Part Foam

|_| Rigid Board

Perimeter to Insulate:

Add Wall Insulation

|_| 2 Part Foam

|_| Rigid Board

Total sq ft:

|_| Vapor Barrier Needed

Total sq ft (include walls):

|_| Seal ducts in crawlspace

Comments:

Heating

Heating System 1

General Information

Heating Code:

Equipment Type:

|_| Gravity Furnace

|_| Forced Air Furnace

|_| Hot Water Boiler

|_| Fixed Electric Resistance

|_| Vented Space Heater

|_| Other

Fuel:

|_| Natural Gas

|_| Oil

|_| Electricity

|_| Other _____________

Location:

|_| Heated Space

|_| Unconditioned Space

|_| Unintentionally Heated

Heat Supplied:

|_| 100%

|_| Other _____________

Manufacturer:

Model #:

Input:

Output:

AFUE:

Age:

Condition:

|_| Good

|_| Fair

|_| Poor (but working)

Programmable T-Stat:

|_| Yes

Automatic Vent Damper:

|_| Present

Pilot Light/IID:

|_| IID

|_| Pilot |_| On in summer

Power Burner:

|_| Yes

Replacement System:

|_| Evaluate Replacement

|_| Tune-up Mandatory

|_| Replace w/High Efficiency

|_| Replace w/Standard

Cabinet size:

|_| Install EC motor upgrade

|_| New Slot |_| New Cover

Additional Costs:

|_| Cond. Pump-New

|_| Cond. Pump-Replace Line

Seal Ductwork

|_| HVAC contractor

|_| WX contractor

Combustion Air:

|_| New

|_| Remove from return

|_| J trap only

|_| Remove humidifier

Other:

Comments:

Damper Type:

|_| None Found

|_| Electric

|_| Thermal

|_| Barometric

|_| None-Recommended

|_| Other

Damper Condition:

|_| Good

|_| Fair

|_| Poor (working)

|_| Broken

|_| Broken-Replace

|_| N/A

Chimney Type:

|_| Masonry-Lined

|_| Masonry-Unlined

|_| Metal

|_| None

|_| Other

Chimney Condition:

|_| Good

|_| Fair

|_| Poor (working)

|_| Broken

|_| None

|_| N/A

Flue Type:

|_| Metal-Single Wall

|_| Metal-Double Wall

|_| PVC

|_| Other

Flue Condition:

|_| Good

|_| Fair

|_| Poor (working)

|_| Broken

|_| N/A

Flue Diameter (in):

Combustion System:

|_| Sealed

|_| Unsealed

Combustion Air:

|_| Adequate

|_| Present-Inadequate

|_| None

|_| Other

Inspections:

|_| Cracked heat exchanger

|_| Insufficient Clearance

|_| Gas Leak Present

|_| Fuel Shutoff Valve MISSING

|_| Drip Leg MISSING

|_| Any Other Problems

Elec. Service Switch:

|_| Good

|_| Fair

|_| Poor (working)

|_| Broken

|_| None

|_| N/A

Thermostat:

Thermostat Type:

|_| Bimetal

|_| Mercury Bulb

|_| Elec-(no setback)

|_| Elec-Setback

|_| Powerpile

Daytime Setting:

Nighttime Setting:

Anticipator Setting:

|_| Relocate

|_| Adjustment Needed

Furnace Components:

|_| Adjustable Control Settings Fan On: | Fan Off: |High Limit: | |_| Limit not working

Burner Type:

|_| Ribbon

|_| Power

|_| Upshot

|_| Flame Retention

|_| Other

Burner Condition:

|_| Good

|_| Fair

|_| Poor (working)

|_| Broken

|_| None

|_| N/A

Pilot Type:

|_| On in Summer

|_| Off in Summer

|_| Hot Surface

|_| IID

|_| Other

Blower Type:

|_| Direct

|_| Belt

Blower Condition

|_| Clean

|_| Dirty

|_| Plugged

Belt Condition:

|_| Good

|_| Fair

|_| Poor (working)

|_| Broken

|_| None

|_| N/A

Humidifier:

|_| Good

|_| Fair

|_| Poor (working)

|_| Broken

|_| None

Elect Air Cleaner

|_| Good

|_| Fair

|_| Poor (working)

|_| Broken

|_| None

AC Coil:

|_| Good

|_| Fair

|_| Poor (working)

|_| Broken

|_| None

Filter Size:

Filter Condition:

|_| Clean

|_| Fair

|_| Dirty

|_| Plugged

|_| None

Boiler Components:

|_| ASBESTOS PRESENT |_| REMOVAL REQUIRED

System Type:

|_| Gravity

|_| Pump

Pump Location:

|_| Supply

|_| Return

Xtank Condition:

|_| Good

|_| Fair

|_| Poor (working)

|_| Broken

Drain Valve Condition:

|_| Good

|_| Fair

|_| Poor (working)

|_| Broken

General Condition:

|_| Good

|_| Fair

|_| Poor (working)

|_| Broken

|_| T/P Valve Present

Pressure Reading:

|_| Low Water Cutoff

AquaStat Setting:

Convector Type:

|_| Radiator

|_| Baseboard

|_| Both

|_| Operable in Each Room

|_| Operable in Unconditioned Space

|_| Client knows how to use Radiator Key

|_| Zone Valves Present

Zone Valve Type/Model:

Zone Valve Condition:

|_| Good

|_| Fair

|_| Poor (working)

|_| Broken

Comments:

Baseloads

Water Heating

General Information

Manufacturer:

Model #:

Fuel:

|_| Natural Gas

|_| Oil

|_| Electricity

|_| Other

Input:

Age:

Location:

|_| Heated Space

|_| Unconditioned Space

|_| Unintentionally Heated

Size (gallons):

|_| 30

|_| 40

|_| 50

|_| 75

|_| Water heater wrap present

|_| Pipe wrap present

Original Tank Insulation (in):

Insulation Type:

|_| Fiberglass

|_| Polyurethane

Inspections

|_| Insufficient Clearance

|_| Gas Leak Present

|_| Fuel Shutoff Valve MISSING

|_| Drip Leg MISSING

Elec. Service Switch:

|_| Good

|_| Fair

|_| Poor (working)

|_| Broken

|_| None

|_| N/A

Hot Water Temp:

|_| Temp adjustment Needed

|_| Relief Piping Needed

|_| Water Leak Present

Damper Type:

|_| None Found

|_| Electric

|_| Thermal

|_| Barometric

|_| None-Recommended

|_| Other

Damper Condition:

|_| Good

|_| Fair

|_| Poor (working)

|_| Broken

|_| Broken-Replace

|_| N/A

Chimney Type:

|_| Masonry-Lined

|_| Masonry-Unlined

|_| Metal

|_| None

|_| Other

Chimney Condition:

|_| Good

|_| Fair

|_| Poor (working)

|_| Broken

|_| None

|_| N/A

Flue Type:

|_| Metal-Single Wall

|_| Metal-Double Wall

|_| PVC

|_| Other

Flue Condition:

|_| Good

|_| Fair

|_| Poor (working)

|_| Broken

|_| N/A

Replacement System:

|_| Replace with PV unit

|_| Replace with Atmospheric

|_| Re-vent to 4

|_| Fix Venting Issues:

Flue Diameter:

Combustion Air:

|_| Adequate

|_| Present-Inadequate

|_| None

|_| Other

Combustion Air:

|_| New

|_| Remove from return

|_| J trap only

|_| PV Exists-Needs GFI

|_| Other:

Comments:

Revised July 2015 Energy Audit

Data Collection Form | 18

Heating Plant

Flue Gas Analysis

Inlet temp:

Flue Gas Temp:

Net Stack Temp:

% Oxygen:

% CO2:

Smoke #:

SSE:

Carbon Monoxide

CO in flue (ppm):

CO free air (ppm):

Heat Rise Test

Return:

Supply:

Heat Rise:

Rated Heat Rise:

Multi Chamber Heating Plant

Inlet temp:

Flue Gas:

Net Stack:

% Oxygen:

% CO2:

SSE:

CO in Flue:

CO Free Air:

DHW

Flue Gas Analysis

Inlet temp:

Flue Gas Temp:

Net Stack Temp:

% Oxygen:

% CO2:

Smoke #:

SSE:

Carbon Monoxide

CO in flue (ppm):

CO free air (ppm):

Comments:

Refrigerator

General Information

|_| Replace -- Other funding source

|_| Replace Evaluate w/DOE

Manufacturer:

Model:

Size (cu ft):

|_| 14

|_| 15

|_| 16

|_| 17

|_| 18

|_| 21

|_| Other:

Location:

|_| Heated Space

|_| Unconditioned Space

|_| Unintentionally Heated

Style:

|_| Top Freezer

|_| Bottom Freezer

|_| Side by Side

|_| Single Door

|_| Single Door w/ Freezer

|_| Other

Defrost:

|_| Auto

|_| Manual

Age:

|_| < 5

|_| 5-9

|_| 10-15

|_| >15

Door Seal:

|_| Good

|_| Fair

|_| Poor

Comments:

Health and Safety

Smoke/CO Alarms

SMOKE ALARM

CO ALARM

Location

Working

< 5 years

Install New

Location

Working

< 5 years

Install New

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COMBO SMOKE/CO ALARM

Total Smoke to Install:

Total CO to Install:

Total COMBO Smoke/CO:

|_|

|_|

|_|

|_|

Comments:

|_|

|_|

|_|

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Equipment

|_| Wood Stove/Fireplace is present

|_| Improper venting

|_| Combustion air is inadequate

|_| Clothes Dryer improper venting

Exhaust Fans

Bathroom

|_| Missing

|_| Not Operational

|_| Improper Vent

Kitchen

|_| Missing

|_| Not Operational

|_| Improper Vent

|_| Air-to-Air Exchanger Exists

Fan measurements on "Blower Door Testing Form"

|_| Dryer Venting VENT ONLY

|_| Dryer Venting HOOD ONLY

|_| Dryer Venting VENT AND HOOD

|_| Clean/Tune Oven

|_| Clean/Tune Stove Top Burners

|_| Repair Gas Leak At Cook Stove

Install Exhaust Fan(s)

Location:

|_| Motion |_|Switch |_| Low Profile

|_| w/Light

|_| Range Hood (standard)

|_| Range Hood (Venmar)

Accessible Attic Above? |_| Yes |_|No |_| N/A

Possible Venting Locations:

|_| Gable |_| Roof |_| Other:

Additional Instructions:

|_| Revent Existing Fan(s)

Location(s):

|_| Service Existing Fan

Location(s):

|_| Install 2nd Fan (list instructions in Comments)

|_| Other:

CO Measurement Oven:

LF Burner 1:

LR Burner 2:

RF Burner 3:

RR Burner 4:

Gas Leak Present

|_|

Comments:

Attic

|_| Recessed Lights Present

|_| Chimney/Flue Shielding

|_| Wiring Problems

|_| Ventilation Inadequate

|_| Water Leaks Present

|_| Moisture/Mold Evident

|_| Vermiculite Present

Other Problems:

Walls

|_| Wiring Problems

|_| Water Leaks Present

|_| Moisture/Mold Evident

|_| Lead Base Paint is Likely

|_| Asbestos in Siding is Likely

Other Problems:

Basement/Crawlspace

|_| Vapor Barrier Needed

|_| Wiring Problems

|_| Water Leaks Present

|_| Plumbing Leaks Present

|_| Moisture/Mold Evident

Other Problems:

Comments:

Building Shell-Windows

Jalousie

Wood

Single Pane

Fixed

Awning

Slider

Skylight

Metal

Wood or Vinyl

Improved Metal

Metal Storm/Single

Fixed

Bad Storm/Single

Door window

Double Pane

Very Tight

Tight

Medium

Loose

Quite Loose

Comments:

Code(s)

Type

Leakiness

Width

Height

Wall

#

Repair

VT / T / M / L / QL

|_|

VT / T / M / L / QL

|_|

VT / T / M / L / QL

|_|

VT / T / M / L / QL

|_|

VT / T / M / L / QL

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VT / T / M / L / QL

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VT / T / M / L / QL

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VT / T / M / L / QL

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VT / T / M / L / QL

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VT / T / M / L / QL

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VT / T / M / L / QL

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VT / T / M / L / QL

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VT / T / M / L / QL

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VT / T / M / L / QL

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VT / T / M / L / QL

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VT / T / M / L / QL

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VT / T / M / L / QL

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VT / T / M / L / QL

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Building Shell-Doors

Code(s)

Type

Leakage

Storm

W

H

#/Wall

HCW WSC IS

SPSG DPSG

T / M / L

A D N

W/S Sweep

HCW WSC IS

SPSG DPSG

T / M / L

A D N

W/S Sweep

HCW WSC IS

SPSG DPSG

T / M / L

A D N

W/S Sweep

HCW WSC IS

SPSG DPSG

T / M / L

A D N

W/S Sweep