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What is the first letter of your mother's first name? (e.g., Mary = M)

What is your house number? (e.g., if you live at 321 Main St., enter 321)

What is your middle initial (if none, use X)?

What is the number of the month you were born? (e.g., May = 5)

How often does your household do the following?

	Never	Rarely	Sometimes	Often	Always	N/A
Keep the heat turned down when sleeping	Never	Rarely	Sometimes	Often	Always	N/A

Keep the heat turned down when no one is home	Never	Rarely	Sometimes	Often	Always	N/A

Wear more clothes instead of turning up the heat	Never	Rarely	Sometimes	Often	Always	N/A

Use fans instead of air conditioning	Never	Rarely	Sometimes	Often	Always	N/A

Consider whether the air conditioner needs to be on	Never	Rarely	Sometimes	Often	Always	N/A

Set the air conditioning to a warmer temperature when leaving the house	Never	Rarely	Sometimes	Often	Always	N/A

Turn off unnecessary lights	Never	Rarely	Sometimes	Often	Always	N/A

Use compact fluorescent light bulbs	Never	Rarely	Sometimes	Often	Always	N/A

Turn off computer(s) and accessories when not in use	Never	Rarely	Sometimes	Often	Always	N/A

Turn off T.V. when no one is watching it	Never	Rarely	Sometimes	Often	Always	N/A

	Never	Rarely	Sometimes	Often	Always	N/A
Turn electronic devices completely off by unplugging them or controlling them with a power strip	Never	Rarely	Sometimes	Often	Always	N/A

Leave electrical chargers (e.g., for cell phone) plugged in	Never	Rarely	Sometimes	Often	Always	N/A

Wash only full loads of laundry	Never	Rarely	Sometimes	Often	Always	N/A

Wash laundry in cold water	Never	Rarely	Sometimes	Often	Always	N/A

Take showers of 5-7 minutes or less	Never	Rarely	Sometimes	Often	Always	N/A

Avoid letting the faucet run	Never	Rarely	Sometimes	Often	Always	N/A

Run only full loads in the dishwasher	Never	Rarely	Sometimes	Often	Always	N/A

Air dry dishes in the dishwasher instead of using heated dry	Never	Rarely	Sometimes	Often	Always	N/A

Air dry laundry during warm weather months	Never	Rarely	Sometimes	Often	Always	N/A

Air dry laundry during winter months	Never	Rarely	Sometimes	Often	Always	N/A

	Never	Rarely	Sometimes	Often	Always	N/A
Walk or bike instead of driving	Never	Rarely	Sometimes	Often	Always	N/A

Take the bus or carpool instead of driving	Never	Rarely	Sometimes	Often	Always	N/A

Leave the engine running while the car is parked	Never	Rarely	Sometimes	Often	Always	N/A

Consider whether I really need to drive somewhere	Never	Rarely	Sometimes	Often	Always	N/A

Plan errands to minimize number of car trips	Never	Rarely	Sometimes	Often	Always	N/A

Below are the activites you indicated that you rarely or never do. There are many reasons that people don't do these activities.

Please check all of the reasons that apply to you.

	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object
Keep the heat turned down when sleeping	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object

Keep the heat turned down when no one is home	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object

Wear more clothes instead of turning up the heat	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object

Use fans instead of air conditioning	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object

Consider whether the air conditioner needs to be on	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object

Set the air conditioning to a warmer temperature when leaving the house	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object

Turn off unnecessary lights	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object

Use compact fluorescent light bulbs	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object

Turn off computer(s) and accessories when not in use	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object

Turn off T.V. when no one is watching it	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object

	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object
Turn electronic devices completely off by unplugging them or controlling them with a power strip	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object

Leave electrical chargers (e.g., for cell phone) plugged in	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object

Wash only full loads of laundry	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object

Wash laundry in cold water	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object

Take showers of 5-7 minutes or less	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object

Avoid letting the faucet run	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object

Run only full loads in the dishwasher	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object

Air dry dishes in the dishwasher instead of using heated dry	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object

Air dry laundry during warm weather months	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object

Air dry laundry during winter months	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object

	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object
Walk or bike instead of driving	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object

Take the bus or carpool instead of driving	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object

Leave the engine running while the car is parked	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object

Consider whether I really need to drive somewhere	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object

Plan errands to minimize number of car trips	I don't think about it	I don't know how	It's too much effort	It takes too much time	It would be uncomfortable	Someone else in my home would object

What activities did you do this week to meet the Energy Challenge?

	1-5 miles	6-10 miles	11-15 miles	16-20 miles	>20 miles
Walked instead of driving	1-5 miles	6-10 miles	11-15 miles	16-20 miles	>20 miles

Biked instead of driving	1-5 miles	6-10 miles	11-15 miles	16-20 miles	>20 miles

Took the bus instead of driving	1-5 miles	6-10 miles	11-15 miles	16-20 miles	>20 miles

Carpooled instead of driving	1-5 miles	6-10 miles	11-15 miles	16-20 miles	>20 miles

Telecommuted	1-5 miles	6-10 miles	11-15 miles	16-20 miles	>20 miles

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