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Learn how you can increase your home’s comfort and health, and decrease your utility bills at the same time by answering a few simple questions about energy use in your home.

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• Your email address:

Contact

• Your first name:
• Your last name:
• Your home phone number:
• Your mobile phone number:
• Your street:
• Your city:
• Your state: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
• Your zip code: 5 digits
• Describe yourself: Owner Tenant
• Where did you first see or hear about us? Select Here Town-Sponsored Event LIGH Literature LI Green Homes Employee Town of Babylon Employee LIGreenHomes.com Power Up Communities - LIPC Newspaper Article Lawn Sign Word of Mouth Private Contractor Other (please specify)
• Which contractor? Select Here American AWS Bayview Custom Construction BrightHome Energy Solutions Community Environmental Center Econo-Therm Insulation Energy Master & Environmental Solutions Energy Testing Services Green Audit USA Greenworks Solutions Home Performance Technologies Master Mechanical Murtha Construction Powersmith Radiant Insulation Raia Insulation Residential Energy Conservation Solar Energy Haus Triple H Contracting Well Home Erol's Plumbing and Heating Fox's Plumbing and Heating Heller Plumbing JPR Plumbing New Comfort Systems Universal Plumbing and Heating
• How many years have you been living in your home? Select Here 0-1 1-2 2-5 5-10 10-20 20-30 30+ Don't know

Building

Please fill out these questions to the best of your ability. All questions are optional, so if you don't know something, you don't have to enter anything.

• Year your home was built: 4 digits Tip
• Size of your home: sq. feet Tip
• Number of stories:
  Number of stories: 1 1.5 2 2.5 3 3.5 4
  Tip
• Number of people in the home:
  Number of Occupants 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
• Type of home: Select Here Apartment Condominium Single-family Detached Single-family Attached Manufactured home Mobile Home Don't know
• Style of your home: Select Here Cape Split-Level Colonial Ranch Duplex Other Don't know
• Is this a two-family home? Yes No
• Number of bedrooms in the home:
  Number of bedrooms in the home: 0 1 2 3 4 5 6 7 8 9 10
• Age of the roof: Select Here 0-5 5-10 10-15 15-20 20-30 30+ Don't know
• Number of entrances to the house:
  Number of entrances to the house: 0 1 2 3 4 5 6 7 8 9 10
• Can you get to every room in your house without walking outside? Yes No
• Type(s) of foundation covering at least 25% of the footprint for the home: Basement Crawl space Slab on grade Tip
• Type of basement: Select Here Finished Unfinished Partial
• Is it a heated basement? Yes No
• Is there a door at the basement stairs? Yes No
• Depth of attic insulation (inches): Select Here 0 1-3 4-6 7-9 10-12 13+ Don't Know
• How well is the insulation distributed in your attic? Select Here Excellent Fair Poor No Insulation Not Sure
• Do you use your attic for storage? Yes No
• Is your attic accessible? Yes No
• Type of windows installed in home: Select Here Double pane Double pane + low e Single pane Single pane + storm Triple pane + low e Don't Know Tip
• Type of window frames: Select Here Metal Vinyl Wood or metal clad Don't Know Tip
• Window condition: Select Here Excellent Good Fair Poor Don't Know
• Which home energy upgrades or weatherization improvements have you previously made in your home?
  • Ducts sealed Tip
  • Modern furnace or boiler (80% AFUE) Tip
  • Very efficient furnace or boiler (90%) installed Tip
  • Home air sealed Tip
  • New exterior door or exterior storm door added Tip
  • Ultra efficient air-conditioning (14+ SEER) installed Tip
  • Walls insulated Tip

Heating Equipment

• Do you have more than one boiler or furnace? Yes No
• If yes, please describe:
• Main heating energy source Select Here None (or not used) Electricity Fuel oil Natural Gas Propane Solar Don't Know Tip
• Type of heater Select Here Boiler Electric Baseboard Furnace Heat pump Don't Know Tip
• Age of heating equipment (years) Select Here 0-5 5-16 16-40 41+ Don't Know Tip
• Programmable thermostat(s) installed? Installed Tip
• Number of thermostats:
  Number of thermostats: 0 1 2 3 4 5 6 7 8 9 10
• Heating thermostat when someone is home
  Thermostat Setting While At Home 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90
  Tip
• Heating thermostat when no one is home or when you're asleep
  Thermostat while homeowners are away 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90
  Off Tip
• Are there currently any radiators, baseboards, or ducts not operating? Yes No
• If yes, please describe:
• Do you use an electric space heater(s)? Yes No
• Number of fireplaces or woodburning stoves:
  Number of fireplaces or woodburning stoves: 0 1 2 3 4 5 6 7 8 9 10
• Do you have your heating system serviced annually? Yes No

Cooling Equipment

• Type of Cooling System Select Here None (or not used) Central AC Evaporative cooler Heat Pump Wall AC Window AC Don't Know Tip
• Age of cooling equipment (years) Select Here 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36+ Don't Know Tip
• Cooling thermostat when someone is home
  Thermostat while homeowners are at home 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90
  Tip
• Cooling thermostat when no one is home or when you're asleep
  Thermostat while homeowners are away 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90
  Off Tip
• Water heating energy source Select Here None Electricity Fuel oil Natural Gas Propane Solar Don't Know Tip
• Water heater type: Select Here Standard Tank Tank with extra insulation Tankless (on-demand) Don't Know Tip
• Age of water heater (years) Select Here 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36+ Don't Know Tip
• Do you ever run out of hot water? Yes No
• Number of bathroom exhaust fans in your home:
  Number of bathroom exhaust fans in your home: 0 1 2 3 4 5 6 7 8 9 10
• Number of kitchen exhaust fans in your home:
  Number of kitchen exhaust fans in your home: 0 1 2 3
• Is your dryer vented to the outside? Yes No
• Do you use a dehumidifier? Yes No
• Do you use a humidifier? Yes No

Refrigerators

• Number of refrigerators:
  Number of refrigerators: 0 1 2 3
• Age of main refrigerator (in years) Select Here 0-5 6-10 11-15 16-20 21-25 26-30 31-35 36+ Don't Know Tip
• Number of standalone freezers
  Number of Freezers 0 1 2 3
  Tip

Appliances

• Type of stove Select Here None Electric Natural gas Propane Don't Know Tip
• Type of range/oven Select Here None Electric Natural gas Propane Don't Know Tip
• Type of clothes dryer Select Here None Electric Natural gas Propane Don't Know Tip
• How much of your lighting comes from Compact Fluorescent Lights (CFLs)? Select Here 0% 1-25% 26-50% 51-75% 76-99% 100% Don't Know Tip

Utilities

• Highest monthly summer electric bill: $ Tip
• Lowest monthly electric bill when you were not on vacation: $ Tip
• Highest monthly winter heating bill: $ Tip
• Lowest monthly fuel bill when you were not on vacation: $ Tip
• Gallons of fuel oilpropane that you have used in the last 12 months: Gallons Tip
• - OR -
• How much did you spend on fuel oilpropane in the last 12 months? $

Problem Areas

• Do you have any rooms that are often too hot or too cold? Yes No
• If yes, please describe:
• Does your home have a tendency to cycle from too hot to too cold? Yes No
• If yes, please describe:
• Are there any known moisture or condensation problems in your home? Yes No
• If yes, please describe:
• Does the basement get wet at any time? Yes No
• If yes, please describe:
• Do icicles ever form on the eves or gutters during the winter? Yes No
• If yes, please describe:
• Does your roof ever leak? Yes No
• If yes, please describe:
• Do you know of any mold or mildew in your home? Yes No
• If yes, please describe appearance and location:

Health Issues

• Do any occupants of the home suffer from chronic headaches, colds, flu, nausea, or asthma? Yes No
• If yes, please describe:
• Do any of the occupants suffer from dry skin in the winter? Yes No
• If yes, please describe:

Concerns

• Please describe any other concerns or problem areas that are affecting your home that weren't asked on this form.

General

• Are you currently undergoing or planning to undertake home renovations? Yes No
• If yes, please describe:
• Is there any sheetrock missing from your home's walls? (Even if there is a small patch missing, please note) Yes No
• If yes, please describe:
• What is your primary reason for seeking a home energy assessment? (Rank with 1 as the highest. Leave blank if not a reason)
  • Energy Bill Reduction
  • Home Comfort Issues
  • Home Health Issues
  • Reduce Carbon Footprint
  • Solar
  • Increase Home's Value
  • Other
• I understand that I must submit the two most recent years of utility usage data for my home. Yes, I will send 2 years of utility usage data as soon as possible Yes, I will contact your office
• Are you aware of any asbestos inside your home or basement/crawlspace? Yes No