EIA-871D District Steam/Hot Water Usage

2012 Commercial Buildings Energy Consumption Survey (CBECS)

Sponsored by the Energy Information Administration

U.S. Department of Energy

Washington, DC 20585

Case Label Here

District Steam/Hot Water Usage Form

(Form EIA-871D)

Form approval
OMB No.: 1905-0145

Expires: xx/xx/xxxx

Look at the label and indicate the type of unit for which you are instructed to provide information:

 Entire building

 Establishment or business within the building

In the following questions, the entire building or establishment within the building will be referred to as the reporting unit.

Complete this form and return it by xx xx, xxxx. Reporting is mandatory under Public Law 93-275, as amended. If you have any questions, please call (toll-free) 1-888-xxx-xxxx and ask for [CONTRACTOR].

Title 18 U.S.C. 1001 makes it a criminal offense for any person knowingly and willingly to make to any Agency or Department of the United States any false, fictitious, or fraudulent statements as to any matter within its jurisdiction.

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time of reviewing instructions, searching existing data records, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Energy Information Administration, Office of Survey Development and Statistical Integration, EI-21, Washington, DC 20585-0670, and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, DC 20503.

C ONTACT INFORMATION

Please provide the following information for the person who completed this form.
(Use each box for individual letters, numbers, characters, or spaces. Please print in CAPS.)

Name: 

Job Title: 

Company: 

E-Mail Prefix: 

E-Mail Domain: 

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@

Y

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Example:

Telephone: 

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Fax Number: 

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G ENERAL INSTRUCTIONS

Reporting format: Report the requested information on this form, or in a format that is convenient for you, such as a computer printout. Make sure the alternate format includes the required information. Examples of completed forms and Frequently Asked Questions are available on the Energy Information Administration website at: http://www.eia.gov/consumption/commercial/ess

Privacy of account numbers: We identify buildings only by the CBECS building identification number, shown on the label on the first page; we do not need your individual account numbers. If you have privacy concerns for your customers, please mark out or omit your own account numbers from any submissions. However, make sure you write the CBECS building identification number on any forms or printouts you send us.

Multiple accounts: Submit a single report for the entire reporting unit summing across all accounts. The total should include former customers who occupied the space during the reporting period. If it is easier, you may provide a separate report for each of the accounts and we will aggregate the data for you.

Reporting Period: Please report district steam/hot water data for all of 2012. We ask for the 16 month period that begins with November 2011 and ends with February 2013; this ensures your report covers the entire calendar year plus two months before and after.

NOTE: If it is easier for you to report district steam/hot water deliveries on a monthly basis, you may complete the Optional Worksheet at the end of this survey form as a substitute for Step 5, questions 1 through 3. After completing the Optional Worksheet, please go back to Step 5, question 4.

1. What is the total amount of district steam/hot water delivered to the reporting unit during the period from November 2011 to February 2013?

(round to nearest unit)

What units are the district steam/hot water reported in? (Check one)

 Million Btu

 Thousand pounds

 Pounds

 Other, specify ______________________________________

2. What is the total cost of the district steam/hot water delivered to the reporting unit during the period from November 2011 to February 2013?

U.S. Dollars (round to nearest dollar)

3. What are the starting and ending dates for the district steam/hot water deliveries?

Starting Date:
M	M	D	D	Y	Y
Ending Date:
M	M	D	D	Y	Y

4. Is the reporting unit billed for the district steam or hot water piped into it?

 Yes

 No

 Don’t Know

5. Is the reporting unit, itself, a heating plant (i.e., does it contain the equipment used to supply district steam/hot water to other buildings)?

 Yes

 No

 Don’t Know

C overage Information:

1. Does the information reported include deliveries or sales to any other building(s) or unit(s) other than the reporting unit?

 Yes  The information includes substantial deliveries or sales to buildings or units other than the reporting unit and you were unable to report separately for the reporting unit.  Continue with Question 2 (below).

 No  The information includes deliveries or sales for only the reporting unit (or the reporting unit and minor out-buildings, such as a shed).  Go to Step 7.

 Don’t Know

2. In your estimation of the total consumption reported in Step 5, Question 1
(or the consumption reported on the optional worksheet), what percentage was consumed
by the reporting unit?

%

Go to Step 7. If you can’t estimate the percentage, continue with Question 3 (below).

3. What is the square footage of the reporting unit?

Square feet (reporting unit)

4. What is the square footage of all of the buildings or units on the district loop,
including the reporting unit?

Square feet (district loop)

Return your Completed Questionnaire(s):

Please use the enclosed FedEx label and envelope to return the questionnaire(s) to:		United States Department of Energy c/o [CONTRACTOR] STREET. CITY, STATE ZIPCD-PLUS
Or you may FAX a copy of the completed form to NORC at:		1-800-xxx-xxxx

Thank you for completing this form.

Optional Worksheet — District Steam/Hot Water Deliveries, Calendar Year 2012

Delivery Period	End Date (first period should include 11/2011)						Amount of District Steam/Hot Water Delivered									Total Costs
#	MM		DD		YY		(enter only numeric values and indicate units below)									U.S. Dollars ($) and Cents (¢) (enter only numeric values)
1																								.
2																								.
3																								.
4																								.
5																								.
6																								.
7																								.
8																								.
9																								.
10																								.
11																								.
12																								.
13																								.
14																								.
15																								.
16																								.
What units did you report the district steam/hot water amount in? (mark with an “x”)
 Million Btu
 Thousand pounds
 Pounds
 Other units, specify
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