Assessment Worksheet

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Outside Relative Humidity:

• Outside Air Temperature:

• Day of the week

  Select Monday Tuesday Wednesday Thursday Friday Saturday Sunday

  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
  • Saturday
  • Sunday

1.) Heating, ventilation, and air conditioning equipment in compliance with organization guidelines

• Thermostat settings meet guidelines.

  Yes

  No

  N/A

• Building temperatures meet guidelines .

  Yes

  No

  N/A

• Fan coil units properly set-back.

  Yes

  No

  N/A

• Night/weekend/holiday set-back procedures followed per regulation 494-1.

  Yes

  No

  N/A

• Boiler/circulating pump operating times OK

  Yes

  No

  N/A

• Time clocks/EMS set correctly.

  Yes

  No

  N/A

• Vestibule/stairwell heaters turned to OFF at night.

  Yes

  No

  N/A

• Domestic hot water circulating pumps off during unoccupied times.

  Yes

  No

  N/A

• What are the enter and leave water temperatures for the boilers?

Boiler Temperatures

• Enter water temperature:

• Leave water temperature:

• What are the enter and leave water temperatures for chiller?

Chiller Temperatures

• Enter water temperature:

• Leave water temperature:

• Other

2.) Doors and windows:

• Exterior/vestibule doors shut when heating/cooling in use.

  Yes

  No

  N/A

• Windows shut.

  Yes

  No

  N/A

• Instruction room doors shut when heating/cooling air in use.

  Yes

  No

  N/A

• Weather stripping okay.

  Yes

  No

  N/A

• Other

3.) Computers and peripherals:

• Off at night.

  Yes

  No

  N/A

• Sleep mode during occupied.

  Yes

  No

  N/A

• Audio-visual equipment OFF

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

4.) Lighting OFF in unoccupied:

• Instruction rooms

  Yes

  No

  N/A

• Offices

  Yes

  No

  N/A

• Library

  Yes

  No

  N/A

• Dining area

  Yes

  No

  N/A

• Kitchen

  Yes

  No

  N/A

• Hallways

  Yes

  No

  N/A

• Lounges

  Yes

  No

  N/A

• Workrooms

  Yes

  No

  N/A

• Restrooms

  Yes

  No

  N/A

• Gymnasium

  Yes

  No

  N/A

• Locker rooms

  Yes

  No

  N/A

• Field houses

  Yes

  No

  N/A

• Stadium/press box

  Yes

  No

  N/A

• Storage rooms

  Yes

  No

  N/A

• Mechanical rooms

  Yes

  No

  N/A

• Custodian closets

  Yes

  No

  N/A

• Auditorium

  Yes

  No

  N/A

• Security lights/time clocks adjusted correctly

  Yes

  No

  N/A

• Other

5.) Plumbing/irrigation:

• Organization's water guidelines being observed

  Yes

  No

  N/A

• Water fountains operating properly

  Yes

  No

  N/A

• Faucets operating properly

  Yes

  No

  N/A

• Commodes and urinals properly adjusted

  Yes

  No

  N/A

• Mechanical room plumbing OK

  Yes

  No

  N/A

• Cooling tower operating properly

  Yes

  No

  N/A

• Other

6.) Miscellanous:

• Copiers, office equipment OFF

  Yes

  No

  N/A

• Exhaust fans OFF in non-critical areas

  Yes

  No

  N/A

• Logger data being collected.

  Yes

  No

  N/A

• Personal appliances?

  Yes

  No

  N/A

• Other

• Energy Specialist

  Sign