Assessment Worksheet - MS

• 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

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 lowest setting at night.

  Yes

  No

  N/A

• Domestic hot water circulating pumps off during unoccupied times.

  Yes

  No

  N/A

• Mechanical rooms lights off.

  Yes

  No

  N/A

• Security lights/time clocks adjusted correctly

  Yes

  No

  N/A

• Exhaust fans OFF in non-critical areas

  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

Building Envelope

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

  Yes

  No

  N/A

• Windows shut.

  Yes

  No

  N/A

• Weather stripping and door sweeps okay.

  Yes

  No

  N/A

• Other

General Building

• Hallway lights off.

  Yes

  No

  N/A

• Restroom lights off.

  Yes

  No

  N/A

• Lounge lights off.

  Yes

  No

  N/A

• Workroom lights off.

  Yes

  No

  N/A

• Storage rooms lights off.

  Yes

  No

  N/A

• Custodian closets lights off.

  Yes

  No

  N/A

• Copiers, office equipment OFF

  Yes

  No

  N/A

• Other.

Administration

• Offices lights off.

  Yes

  No

  N/A

• Computers shutdown (except Wed and Thurs) and monitors off

  Yes

  No

  N/A

• Copiers, office equipment OFF

  Yes

  No

  N/A

• Other.

Library/Media Center

• Library lights off.

  Yes

  No

  N/A

• Computers shutdown (except Wed and Thurs) and monitors off

  Yes

  No

  N/A

• Other.

Kitchen/Cafeteria/Multipurpose

• Kitchen lights off.

  Yes

  No

  N/A

• Dining area lights off.

  Yes

  No

  N/A

• Exhaust fans and hoods off.

  Yes

  No

  N/A

• Other.

Classrooms

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

  Yes

  No

  N/A

• Lights off in unoccupied.

  Yes

  No

  N/A

• Computers shutdown (except Wed and Thurs) and monitors off

  Yes

  No

  N/A

• Audio-visual equipment OFF

  Yes

  No

  N/A

• Other.

Gym/Physical Education

• Gymnasium lights off

  Yes

  No

  N/A

• Computers shutdown (except Wed and Thurs) and monitors off

  Yes

  No

  N/A

• Locker rooms lights off.

  Yes

  No

  N/A

• Other.

School grounds and fields

• Other

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

Miscellaneous:

• Logger data being collected.

  Yes

  No

  N/A
Other

• Other

• Add media

  Media

• Energy Specialist

  Sign