Energy Benchmarking
Instructions:
Complete this online Building Data Collection Form for each building and either mail or email the most current 12 consecutive months of utility bills, or a completed and signed Utility Data Release Form to:
Hospital Outpatient Healthcare |
| Business Sector |
| Sector: |
Hospital |
| Segment: |
Outpatient Healthcare |
| If this is Incorrect Please Select a Different Sector or Business Segment |
| Your Information |
| First and Last Name |
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| Email Address |
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| General Information |
| Name of Facility/Building |
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| Address |
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| Address - Continued |
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| City |
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| State |
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| ZIP Code |
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| Contact Person |
| First Name |
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| Last Name |
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| Job Title |
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| Address |
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| Address - Continued |
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| Phone |
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| Email |
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| Fax |
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| Mobile |
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| Building Information |
| Year Built |
e.g.. 2001 |
| Max No. of Employees at One Time |
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| Typical Non-Employee Daily Occupancy |
(non-employees, at one time) |
| Hours of Building Occupancy per Week |
(when the majority of the building is being used) |
| No. of Months Building Operated per Year |
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| Size of Building |
(Sq. Ft.)
(Do not include any unheated areas) |
| No. of Floors |
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| Building Type/Description |
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| Heating System and Fuel Type |
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| Percentage of Building Heated |
% |
| Cooling System |
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| Percentage of Building Cooled |
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| Utility Information |
| Electric Utility |
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| Electric Utility Account No. |
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| Gas Company |
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| Gas Company Account No. |
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| Oil Supplier |
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| Oil Supplier Account No. |
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| Additional Purchased Energy? (Propane, Chilled Water, Steam or Other) |
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| List the Energy Source(s) and Account Information for Additional Purchased Energy: |
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| Other Information |
| Does the facility use any electricity generated on site? |
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| If yes, list the fuel source and amount of each: |
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What are your biggest challenges to implementing energy efficiency measures?
(Check all that apply) |
| Funding |
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| Time |
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| Expertise |
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| Don't know how to get started |
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| Staff |
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| Or Other (Please Explain) |
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| Does the building have cooking facilities? |
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| At what % of total capacity is the building currently operating? |
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| Energy Benchmarking Information |
| Operating Characteristics: |
| Number of Personal Computers: |
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| Commercial Food Preparation Area? |
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| Number of Walk-in Refrigerators: |
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| Number of Walk-in Freezers: |
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| Commercial Laundry on Site? |
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| Has In-Unit (Private) Laundry? |
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| Does the Building have a Pool? (Check all that Apply) |
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| Indoor: |
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| Outdoor: |
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| Olympic 50x25: |
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| Recreational 20x15: |
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| Short Course 25x20: |
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| No. of Months per Year Pool is in Use |
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| Building Operated on Weekends? |
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Commercial Building Energy Consumption Space (CBECS) Areas
Enter the percentage of the gross area that can be characterized as one of the space types listed below. Do not count spaces twice; pick the most specific choice by using subtypes where applicable. For example, if you have a Medical Clinic, list the space in "Clinic/Other" not "Healthcare (Outpatient)." The total should equal 100%. |
| Space Type/Subtype |
% of Gross Area |
| Food Sales |
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| Grocery Store/Food Market: |
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| Convenience Store: |
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| Food Service |
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| Restaurant/Cafeteria: |
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| Fast Food: |
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| Health Care (Inpatient) |
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| Specialty Hospital: |
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| Acute Care Hospital: |
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| Children's Hospital: |
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Health Care
(Long Term Care) |
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| Health Care (Outpatient) |
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| Medical Office: |
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| Clinic/Other: |
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| Lodging |
|
Mall
(Strip Mall or Enclosed) |
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| Office Space |
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| Public Assembly |
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| Entertainment/Culture: |
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| Library: |
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| Recreation |
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| Social/Meeting |
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| Public Order and Safety |
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| Fire/Police Station |
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| Courthouse |
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Service
(Vehicle Repair, Postal Services) |
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| Storage/Shipping/Warehouse |
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| Self Storage |
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| Non-refrigerated Warehouse |
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| Refrigerated Warehouse |
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| Distribution/Shipping Center |
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Retail
(Non-mall Stores, Vehicle Dealership |
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| Other (Please Describe) |
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| Other (Please Describe) |
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Instructions:
Complete this online Building Data Collection Form for each building and either mail or email the most current 12 consecutive months of utility bills, or a completed and signed
Utility Data Release Form to:
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