Energy Retrofit Assessment Form
Use this form to assess a property’s energy performance, identify retrofit opportunities, and gather the information needed to recommend improvements.
Property Overview
Property Type
*
Single-family home
Multi-family building
Townhouse
Apartment/Condo
Commercial space
Other
Property Address or Location
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Year Built
Approximate Floor Area (sq ft)
Number of Floors
Ownership / Occupancy Status
*
Owner-occupied
Tenant-occupied
Vacant
Mixed use
Building Envelope and Systems
Attic Insulation Level
Please Select
None
Low
Moderate
Good
Unknown
Wall Insulation Level
Please Select
None
Low
Moderate
Good
Unknown
Floor Insulation Level
Please Select
None
Low
Moderate
Good
Unknown
Window Type and Condition
Please Select
Single-pane, good condition
Single-pane, poor condition
Double-pane, good condition
Double-pane, poor condition
Triple-pane
Mixed types
Unknown
Door Condition and Drafts
Please Select
Well-sealed, no noticeable drafts
Minor drafts or wear
Moderate drafts or air leakage
Significant drafts or damage
Unknown
Roof Condition
Please Select
Excellent
Good
Fair
Poor
Unknown
Heating Type
Please Select
Natural gas furnace
Electric resistance
Heat pump
Boiler
Oil furnace
Wood stove or fireplace
District heating
Other
Unknown
Cooling Type
Please Select
Central air conditioning
Ductless mini-split
Window unit(s)
Evaporative cooler
Heat pump cooling
None
Other
Unknown
Water Heating Type
Please Select
Tank-style gas
Tank-style electric
Tankless gas
Tankless electric
Heat pump water heater
Solar water heating
Other
Unknown
Ventilation Type
Please Select
Natural ventilation only
Exhaust fans only
Supply ventilation
Balanced ventilation
Heat recovery ventilation
Energy recovery ventilation
Mechanical ventilation unknown
Other
Unknown
Known Envelope Issues or Problem Areas
Energy Use and Comfort Assessment
Monthly energy use and bills
*
Indoor comfort
*
Very uncomfortable
1
2
3
4
Very comfortable
5
1 is Very uncomfortable, 5 is Very comfortable
Draftiness
*
Very drafty
1
2
3
4
Not drafty
5
1 is Very drafty, 5 is Not drafty
Temperature consistency
*
Very inconsistent
1
2
3
4
Very consistent
5
1 is Very inconsistent, 5 is Very consistent
Humidity and moisture concerns
*
Severe concerns
1
2
3
4
No concerns
5
1 is Severe concerns, 5 is No concerns
Noise levels
*
Very noisy
1
2
3
4
Very quiet
5
1 is Very noisy, 5 is Very quiet
Overall energy cost burden
*
Not burdensome
1
2
3
4
Extremely burdensome
5
1 is Not burdensome, 5 is Extremely burdensome
Observed issues
High bills
Uneven temperatures
Drafts
Condensation
Mold or mildew signs
Overheating
Equipment noise
Other
Existing Efficiency Measures and Retrofit Priorities
Current Energy Efficiency Measures Installed
*
LED lighting
Smart thermostat
Upgraded insulation
Air sealing
Energy-efficient windows
High-efficiency HVAC
Heat pump
Solar
None
Other
Desired Retrofit Goals
*
Lower utility bills
Improve comfort
Reduce emissions
Replace old equipment
Prepare for electrification
Increase resilience
Improve indoor air quality
Other
Preferred Retrofit Timeline
*
Immediate
Within 3 months
Within 6 months
Within 12 months
Longer-term planning
Not sure
Budget or Planning Range
Please Select
Under $5,000
$5,000-$15,000
$15,000-$30,000
$30,000-$50,000
Over $50,000
Not determined yet
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