DOE F 413.25 Tool Data Collection Form

OMB Control #:  1910-5184

DOE HQ F 413.25

Exp. Date:  10/31/2019.

DOE HQ F 413.25

Home Energy Scoring Tool

Data Collection Form

Location Information

Address: _______________________________________ City: ____________________ State: _____ Zip: _________

Assessment Type: Initial / Final / QA / Alternative EEM (Energy Efficiency Measures) / Test / Corrected / Mentor / Preconstruction

Assessment Date: ____________________ Assessor: _________________________________________________

Comments: ____________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

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Home Details

Year Built: _______________ # of Bedrooms: 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 # of Stories Above Grade: 1 / 2 / 3 / 4

Average Ceiling Height (ft): 6 / 7 / 8 / 9 / 10 / 11 / 12 Conditioned Floor Area (sq ft): ____________________

Direction Faced by Front of House: N / NE / E / SE / S / SW / W / NW

Air Tightness

Was a Blower Door test conducted on this house?: Yes / No

Air Leakage rate: _______________ cfm50 Has the house been professionally air sealed?: Yes / No

Roof / Attic 1 Attic 1 Area (sq ft): ______________________

Roof Construction: Standard Roof / with Radiant Barrier / with Rigid Foam Sheathing

Exterior Finish: Composition Shingles or Metal / Wood Shakes / Clay Tile / Concrete Tile / Tar & Gravel

Insulation Level (applied to roof): R-0 / R-11 / R-13 / R-15 / R-19 / R-21 / R-27/ R-30

Roof Color: White / Light / Medium / Medium Dark / Dark / Cool Color: ______ (reflectivity)

Attic or Ceiling Type: Unconditioned Attic / Conditioned Attic / Cathedral Ceiling

Attic Floor Insulation: R-0 / R-3 / R-6 / R-9 / R-11 / R-19 / R-21 / R-25 / R-30 / R-38 / R-44 / R-49 / R-60

Roof / Attic 2 Attic 2 Floor Area (sq ft): ______________________

Roof Construction: Standard Roof / with Radiant Barrier / with Rigid Foam Sheathing

Exterior Finish: Composition Shingles or Metal / Wood Shakes / Clay Tile / Concrete Tile / Tar & Gravel

Insulation Level (applied to roof): R-0 / R-11 / R-13 / R-15 / R-19 / R-21 / R-27 / R-30

Roof Color: White / Light / Medium / Medium Dark / Dark / Cool Color: __________ (reflectivity)

Attic or Ceiling Type: Unconditioned Attic / Conditioned Attic / Cathedral Ceiling

Attic Floor Insulation: R-0 / R-3 / R-6 / R-9 / R-11 / R-19 / R-21 / R-25 / R-30 / R-38 / R-44 / R-49 / R-60

Foundation 1 Foundation 1 Area (sq ft): _______________________

Type: Slab-on-Grade / Unconditioned Basement / Conditioned Basement / Unvented Crawlspace /

Vented Crawlspace

Floor Insulation over Basement or Crawlspace: R-0 / R-11 / R-13 / R-15 / R-19 / R-21 / R-25 / R-30 / R-38

Foundation Wall Insulation: R-0 / R-5 (slab only) / R-11 (bsmt/crawl wall) / R-19 (bsmt/crawl wall)

Foundation 2 Foundation 2 Area (sq ft): _______________________

Type: Slab-on-Grade / Unconditioned Basement / Conditioned Basement / Unvented Crawlspace /

Vented Crawlspace

Floor Insulation over Basement or Crawlspace: R-0 / R-11 / R-13 / R-15 / R-19 / R-21 / R-25 / R-30 / R-38

Foundation Wall Insulation: R-0 / R-5 (slab only) / R-11 (bsmt/crawl wall) / R-19 (bsmt/crawl wall)

Walls

Is this home a Townhouse or Duplex?: Yes / No Position of Unit: Middle / Right / Left

Wall Characteristics: Front or All (circle one)

Construction: Wood Frame / Wood Frame with rigid foam sheathing / Wood Frame with Optimum Value Engineering (OVE) / Structural Brick / Concrete Block or Stone / Straw Bale

Exterior Finish: Wood Siding, Fiber Cement, Composite Shingle or Masonite Siding / Stucco / Vinyl Siding / Aluminum Siding / Brick Veneer / none

Wall Insulation: R-0 / R-3 / R-6 / R-7 / R-11 / R-13 / R-15 / R-19 / R-21 / R-27 / R-33 / R-38

Skylights: Yes or No (circle one):

Total Skylight Area (sq. ft.): __________ Number of Panes: Single-pane / Double-pane / Triple-pane

Frame Type: Aluminum / Aluminum with Thermal Break / Wood or Vinyl

Glazing Type: Clear / Tinted / Solar-control low-E / Solar-control low-E, argon gas fill / Insulating low-E / Insulating low-E, argon gas fill

-OR- Actual window specifications = U-Factor (from 0.01 – 5.00): _________ SHGC (from 0.0 – 1.0): ______

Window Area (sq. ft.):

Front: _______________ Back: ________________ Right Side: ______________ Left Side: _______________

Window Characteristics: Front or All (circle one) Solar Screens: Yes / No

Panes: Single-pane / Double-pane / Triple-pane

Frame Type: Aluminum / Aluminum with Thermal Break / Wood or Vinyl

Glazing Type: Clear / Tinted / Solar-control low-E / Solar-control low-E, argon gas fill / Insulating low-E / Insulating low-E, argon gas fill

-OR- Actual window specifications = U-Factor (from 0.01 – 5.00): __________ SHGC (from 0.0 – 1.0): ________

>BACK<

Wall Characteristics: Back

Construction: Wood Frame / Wood Frame with Rigid Foam Sheathing / Wood Frame with Optimum Value Engineering (OVE) / Structural Brick / Concrete Block or Stone / Straw Bale

Exterior Finish: Wood Siding, Fiber Cement, Composite Shingle or Masonite Siding / Stucco / Vinyl Siding / Aluminum Siding / Brick Veneer

Wall Insulation: R-0 / R-3 / R-6 / R-7 / R-11 / R-13 / R-15 / R-19 / R-21 / R-27 / R-33 / R-38

Window Characteristics: Back Solar Screens: Yes / No

Panes: Single-pane / Double-pane / Triple-pane

Frame Type: Aluminum / Aluminum with Thermal Break / Wood or Vinyl

Glazing Type: Clear / Tinted / Solar-control low-E / Solar-control low-E, argon gas fill / Insulating low-E / Insulating low-E, argon gas fill

-OR- Actual window specifications = U-Factor (from 0.01 – 5.00): __________ SHGC (from 0.0 – 1.0): ________

>RIGHT SIDE<

Wall Characteristics: Right Side (facing house)

Construction: Wood Frame / Wood Frame with Rigid Foam Sheathing / Wood Frame with Optimum Value Engineering (OVE) / Structural Brick / Concrete Block or Stone / Straw Bale

Exterior Finish: Wood Siding, Fiber Cement, Composite Shingle or Masonite Siding / Stucco / Vinyl Siding / Aluminum Siding / Brick Veneer

Wall Insulation: R-0 / R-3 / R-6 / R-7 / R-11 / R-13 / R-15 / R-19 / R-21 / R-27 / R-33 / R-38

Window Characteristics: Right Side (facing house) Solar Screens: Yes / No

Panes: Single-pane / Double-pane / Triple-pane

Frame Type: Aluminum / Aluminum with Thermal Break / Wood or Vinyl

Glazing Type: Clear / Tinted / Solar-control low-E / Solar-control low-E, argon gas fill / Insulating low-E / Insulating low-E, argon gas fill

-OR- Actual window specifications = U-Factor (from 0.01 – 5.00): __________ SHGC (from 0.0 – 1.0): ________

>LEFT SIDE<

Wall Characteristics: Left Side (facing house)

Construction: Wood Frame / Wood Frame with Rigid Foam Sheathing / Wood Frame with Optimum Value Engineering (OVE) / Structural Brick / Concrete Block or Stone / Straw Bale

Exterior Finish: Wood Siding, Fiber Cement, Composite Shingle or Masonite Siding / Stucco / Vinyl Siding / Aluminum Siding / Brick Veneer

Wall Insulation: R-0 / R-3 / R-6 / R-7 / R-11 / R-13 / R-15 / R-19 / R-21 / R-27 / R-33 / R-38

Window Characteristics: Left Side (facing house) Solar Screens: Yes / No

Panes: Single-pane / Double-pane / Triple-pane

Frame Type: Aluminum / Aluminum with Thermal Break / Wood or Vinyl

Glazing Type: Clear / Tinted / Solar-control low-E / Solar-control low-E, argon gas fill / Insulating low-E / Insulating low-E, argon gas fill

-OR- Actual window specifications = U-Factor (from 0.01 – 5.00): __________ SHGC (from 0.0 – 1.0): ________

System 1 % of floor area served: ____________________

Heating (System 1)

Type of Heating 1 System: None / Central gas furnace / Room (through-the-wall) gas furnace / Gas boiler / Propane (LPG) central furnace / Propane (LPG) wall furnace / Propane (LPG) boiler / Oil furnace / Oil Boiler / Electric furnace / Electric heat pump / Electric baseboard heater / Ground coupled heat pump / Minisplit (ductless) heat pump / Electric boiler / Wood Stove / Pellet Stove

Heating System 1 Efficiency: Do you know the actual heating system efficiency?: Yes / No*

*You can use the Assessor Calculator to determine the approximate efficiency!

Efficiency Value (AFUE or HSPF): __________________ OR Year Installed: _____________________

Cooling (System 1)

Type of Cooling 1 System: None / Central air conditioner / Room air conditioner / Electric heat pump / Minisplit (ductless) heat pump / Ground coupled heat pump / Direct evaporative cooling

Cooling System 1 Efficiency: Do you know the actual cooling system efficiency?: Yes / No*

*You can use the Assessor Calculator to determine the approximate efficiency!

Efficiency Value (SEER or EER): __________________ OR Year Installed: _____________________

Duct (System 1)

Duct Location 1 (#1): Conditioned Space / Unconditioned basement / Vented crawlspace / Unvented crawlspace / Unconditioned attic

Percentage of Ducts in this location: __________ Are ducts sealed?: Yes / No Are ducts insulated?: Yes / No

Duct Location 1 (#2): Conditioned Space / Unconditioned basement / Vented crawlspace / Unvented crawlspace / Unconditioned attic

Percentage of Ducts in this location: __________ Are ducts sealed?: Yes / No Are ducts insulated?: Yes / No

Duct Location 1 (#3): Conditioned Space / Unconditioned basement / Vented crawlspace / Unvented crawlspace / Unconditioned attic

Percentage of Ducts in this location: __________ Are ducts sealed?: Yes / No Are ducts insulated?: Yes / No

System 2 % of floor area served: ____________________

Heating (System 2)

Type of Heating 2 System: None / Central gas furnace / Room (through-the-wall) gas furnace / Gas boiler / Propane (LPG) central furnace / Propane (LPG) wall furnace / Propane (LPG) boiler / Oil furnace / Oil Boiler / Electric furnace / Electric heat pump / Electric baseboard heater / Ground coupled heat pump / Minisplit (ductless) heat pump / Electric boiler / Wood Stove / Pellet Stove

Heating System 2 Efficiency: Do you know the actual heating system efficiency?: Yes / No*

*You can use the Assessor Calculator to determine the approximate efficiency!

Efficiency Value (AFUE or HSPF): __________________ OR Year Installed: _____________________

Cooling (System 2)

Type of Cooling 2 System: None / Central air conditioner / Room air conditioner / Electric heat pump / Minisplit (ductless) heat pump / Ground coupled heat pump / Direct evaporative cooling

Cooling System 2 Efficiency: Do you know the actual cooling system efficiency?: Yes / No*

*You can use the Assessor Calculator to determine the approximate efficiency!

Efficiency Value (SEER or EER): __________________ OR Year Installed: _____________________

Duct (System 2)

Duct Location 2 (#1): Conditioned Space / Unconditioned basement / Vented crawlspace / Unvented crawlspace / Unconditioned attic

Percentage of Ducts in this location: __________ Are ducts sealed?: Yes / No Are ducts insulated?: Yes / No

Duct Location 2 (#2): Conditioned Space / Unconditioned basement / Vented crawlspace / Unvented crawlspace / Unconditioned attic

Percentage of Ducts in this location: __________ Are ducts sealed?: Yes / No Are ducts insulated?: Yes / No

Duct Location 2 (#3): Conditioned Space / Unconditioned basement / Vented crawlspace / Unvented crawlspace / Unconditioned attic

Percentage of Ducts in this location: __________ Are ducts sealed?: Yes / No Are ducts insulated?: Yes / No

Hot Water:

Water Heater Type: Electric Storage / Natural Gas Storage / LPG Storage / Oil Storage / Electric Instantaneous / Gas Instantaneous / Propane Instantaneous / Electric Heat Pump

Hot Water System Efficiency: Do you know the actual water heater energy factor?: Yes (EF) / Yes (UEF) / No*

*You can use the Assessor Calculator to determine the approximate energy factor (EF)!

Energy Factor (between 0.0 – 1.0): ___________________ OR Year Installed: _____________________

Photovoltaic (PV) System

Year Installed: ___________ Direction Panels Face: N / NE / E / SE / S / SW / W / NW

# of Panels: ____________ or DC Capacity: __________________

Notes:

Assessment Checklist

General Info:

• Year

• # of bedrooms

• Blower door test?

• Professionally air sealed?

• Window specs?

Outside

• House Orientation

• # of stories

• Roof: Predominant exterior finish

• Color

• Walls: Same type on all sides?

• Construction type

• Exterior finish

• Windows: Same on all sides?

• Panes

• Frame

• Glazing

Inside

• Attic

  • Roof Construction

• Insulation type & amount

• Air sealed?

• Air handler present? Type and year

• Ducts?: Insulated? Sealed?

• Upper Floor

  • Square feet

  • Ceiling Height

  • Skylights?

  • Windows

• Main Floor

  • Square feet

  • Ceiling Height

  • Skylights?

  • Windows

  • Walls & insulation

• Crawlspace - insulation type & amount

  • Ducts?: Insulated? Sealed?

• Basement – Conditioned?

  • Square feet

  • Ceiling Height

  • Windows

  • Walls & insulation

• HVAC Equipment

  • Type?

  • Year or SN?

• Water Heater

  • Type?

  • Year or SN?

• PV

  • Age

  • Orientation

  • # of Panels or Capacity

Window Dimensions:

Front		Back		Right		Left

Layout:

Public reporting burden for this collection of information is estimated to average one (1) hour per response, including the time for reviewing instructions, searching existing data sources, 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 Office of the Chief Information Officer, Records Management Division, IM-23, Paperwork Reduction Project (1910-5184), U.S. Department of Energy, 1000 Independence Ave SW, Washington, DC, 20585-1290; and to the Office of Management and Budget (OMB), OIRA, Paperwork Reduction Project (1910-5184), Washington, DC  20503.

Home Energy Score – Data Collection 20

Revised 1/14/2021