Energy Coaches Form Household Questionnaire Form used to help energy coaches understand client goals. First NameLast NameEmail AddressHome AddressDescribe your home:How many living levels? Approximate year built? Have there been insulation projects or major renovations? What and when? Are there major home upgrades needed? What are the current priorities?Do you plan an addition or major renovations or changes to room layout/configuration?How long do you plan to stay in this house?Building EnvelopeHave you considered improvements to your building envelope to improve efficiency?Has your home had an energy audit? Yes No Not sure If so, when was it conducted? What were the findings/what actions were recommended? Have you completed or do you plan to complete these actions?Do you have a copy of the audit we could look at together? Yes No Have you reinsulated your house and done air sealing? When was your home last insulated?Do you have any current comfort issues like uneven heating/cooling or uneven room temperatures, hot/cold spots or drafts, etc?How old are the windows on your home and how do they perform?Is there currently weatherstripping in your home?Electrified home heating, hot water and air conditioningHow urgent is your need to replace your current heating/cooling equipment?ASAPWithin this yearI hope to wait at least a yearWhat is your current heating fuel? Propane Oil Electric Wood or wood pellet Other What is the age of your existing heating system?Is the system functioning well?How is heat distributed in home? Air ducts Hot water radiators or baseboards Radiant floors Steam radiators Other How many square feet of heated/cooled area?Optional question to aid use of Efficiency Maine heating efficiency tool If possible, we’d like to collect the following data as applicable from households we are coaching: CMP bill showing 12 mos of kWh usage Total of CMP payments for 12 months Amount and total expenditures on oil or propane for 12 months Pounds of pellets and expense for 12 months Cords of wood and expense for 12 monthss Air ConditioningDoes your home currently have air conditioning? Yes No What is the age of your existing central A/Csystem? Is the system functioning well?Do you have window units? How many?Are you interested in having A/C in your home?Untitled First Choice Second Choice Third Choice WaterWould you like to know about electrifying your hot water? Yes No Maybe later If so: What fuel is used for domestic hot water, e.g.,gas, oil, propane, electricity? Is hot water integrated with a boiler for home heating?What is the age of your existing water heater?How urgent is your need to replace your current water heater?PrioritiesHelp us better understand what is important to you. Minimize changes to the aesthetics of my home Minimize ongoing heating/cooling energy costs Minimize upfront cost of new system Increase the comfort of my home Reduce carbon footprint Other Please put a check next to the items that are important to you. Electric Car ChargingWould you like to learn more about charging an EV at home?If you know, what is the current electric service to your home [typically 100A – 250A]?Rooftop SolarHave you considered adding solar photovoltaic panels to your home?Age and condition of roof, roofing materialYard space for non-rooftop array?If rooftop/home solar is not an option, interest in Community Solar? Δ
