Completion Report for ENERGY STAR Modular Home 

CONTACT INFORMATION

a)	Rater primary contact	b)	Rater field tester (if different from
primary contact)

Company 		Name 

Company 	Name

Address

Address

City	State	Zip

City	State	Zip

Telephone		Email

Telephone	Email

	

c)	 Factory	d)	Builder

Corporate Parent 	

Company	Name 



Plant name

Address

Plant City	Plant State       Zip	Zip	City	State	Zip



Telephone	Fax

e)	Homeowner	f)	Home location

Name	

	Address

Telephone

City	State	Zip

Was this home tested?     ( Yes   ( No       If No, skip to question 4.
Conditioned space sq. ft.: 	

House tightness (must fill in and check to pass)

ACH50. Measured: ______________ (must be ≤ 7.0 in CZ 1-2 | ≤ 6.0 in
CZ 3-4 | ≤ 5.0 in CZ 5-7 | ≤ 4.0 in CZ 8)	(

DUCT TIGHTNESS (must fill in and check ONE to pass)

Duct leakage to outside at 25 pascals. Measured: ______________ (must be
≤ 4 cfm to outdoors / 100 sq. ft.)	(

All ducts and air handling equipment are in conditioned space and
envelope leakage tests

at ≤ 3 ACH 50 or ≤ 0.25 cfm 50 per sq. ft. of building envelope.	(

QUALITY ASSURANCE (QA) LABEL (must check ONE to pass)

An SBRA quality assurance (QA) ENERGY STAR Modular Home Label is affixed
to the home interior and signed

and dated by a factory representative	(

This home is one of the factory’s initial three certification homes
(QA label will be affixed with site label – see below)	(

RATER EVALUATION (check one)

PASSES: No discrepancies were identified.	(

FAILS: Discrepancies are described on the following sheet.	(

Signature of Rater: 	 	Date: 	

Complete all applicable items and send with a completed copy of the
Inspection Checklist for ENERGY STAR Qualified Modular Homes and, if
home passes, a check for $40 (or $140 if this is one of the initial
three factory certification homes) to: Systems Building Research
Alliance, 2109 Broadway, Suite 200, New York, NY 10023.Description of
problems/discrepancies and remediation actions

Item number:

_____	Discrepancy



















Remediation

















	Item number:

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Energy Star Modular Homes			Rev.   DATE \@ "M/d/yyyy"  9/17/2009 

OMB Control No. xxxx-xxxx

Energy Star Modular Homes	Rev.   DATE \@ "M/d/yyyy"  9/17/2009 

EPA Form 5900-189

The government estimates the average time needed to fill out this form
is 0.50 hours and welcomes suggestions for reducing this effort. Send
comments (referencing OMB Control Number) to the Director, Collection
Strategies Division, U.S. EPA (2822T), 1200 Pennsylvania Ave., NW,
Washington, D.C. 20460.

