1. IS PARTICIPATING FACILITY A SINGLE ENTITY OR PART OF A MULTI-FACILITY ENTERPRISE?
CORPORATE ADDRESS (STREET, CITY, STATE, ZIP):
NUMBER OF FACILITIES:
PARTICIPATING FACILITY NAME:
FACILITY ADDRESS (STREET, CITY, STATE, ZIP):
2. DESCRIBE YOUR FACILITY
INDUSTRY SECTOR AND PRIMARY PRODUCT LINES:
SIZE (NUMBER OF EMPLOYEES):
APPROXIMATE ANNUAL ENERGY EXPENDITURES (AS A PERCENTAGE OF OPERATING EXPENSES): electricity % | natural gas % | fuel oil % | other %
3. DOES YOUR ORGANIZATION CURRENTLY HAVE THE FOLLOWING?
a. Energy management goals? yes no If so, briefly describe:
b. Framework to track progress toward goals? yes no If so, briefly describe:
c. Key performance indicators (KPI’s) for energy, quality, or productivity? yes no If so, briefly describe:
d. An energy team? yes no If so, for how long? yrs/mos
e. Experience with ISO standards? yes no If so, briefly describe:
4. WHAT ARE SOME BENEFITS YOUR FACILITY WISHES TO REALIZE THROUGH PARTICIPATION IN THE NORTHWEST ENERGY MANAGEMENT SYSTEM PILOT? NUMBER THE BOXES
BEGINNING WITH ’1’ AS THE MOST VALUABLE BENEFIT.
a. Energy management system f. Improve energy projects ROI
b. Competitive advantage through energy management g. Improve operations and maintenance
c. Control energy costs h. Record of energy savings and carbon emission reductions
d. Decrease energy intensity i. Other:
e. Prepare for ISO
NORTHWEST ENERGY MANAGEMENT SYSTEM PILOT RACI MATRIX
RACI REPRESENTS: RACI DEFINIT IONS:
R – RESPONSIBILITY RESPONSIBILITY - person or role responsible for actually doing or completing the item
A – ACCOUNT ABLE ACCOUNTABLE - person or role responsible for ensuring that the item is completed
C – CONSULTED CONSULTED - person or role whose subject matter expertise is required in order to complete the it em
I – INFORMED INFORMED - person or role that needs to be kept informed of the status of item completion
Simply place an R, A, C, I or any appropriate combination in each of the applicable roles for each activity. Each activity should have at least one indi vidual accountable while there may be shared
responsibilities depending on the activity.
ROLE SENIOR MANAGEMENT LEAD PROJECT MANAGER PROJECT TEAM MEMBERS OFFSITE: CORPORATE
PROJECT DELIVERABLE (OR ACTIVITY)
Create project budget that includes travel and training
Manage energy bill data
Attend 3 two-and-a-half day workshops
Manage energy purchasing
Approve capital expenditures under 25,000.00
Approve capital expenditures over 25,000.00
Approve O & M supplies and expenses
Specify operating policies & practices regarding high-intensity energy systems:
Successful outcome of pilot project
6. AN IMPORTANT ELEMENT OF THE NORTHWEST ENERGY MANAGEMENT SYSTEM PILOT IS REPORTING ON THE CHALLENGES AND SUCCESSES OF PARTICIPATING FACILITIES.
PROPRIETARY INFORMATION WILL BE PROTECTED. ANY CASE STUDY ON YOUR FACILITY’S PARTICIPATION IN THE PROJECT WILL BE APPROVED BY YOUR SITE BEFORE RELEASE.
Is your site willing to participate in case study reporting? yes no
If not, please indicate why:
7 SENIOR MANAGEMENT SPONSOR
ONGOING SUPPORT FROM TOP MANAGEMENT IS VITAL FOR SUCCESSFUL, SUSTAINABLE ENERGY MANAGEMENT.
a. Is your facility willing to commit to obtaining certification under ISO 50001? yes no
b. Is your facility willing to commit to an energy intensity reduction goal of at least 3% over 3 years? yes no
c. Briefly describe your commitment to ensuring pilot project visibility and value throughout facility.
d. Briefly describe your commitment to directing staff time & involvement to the pilot project.
SENIOR MANAGEMENT SPONSOR
Signature Date V. 1