Download Home Energy Inspection - Suffolk County Council

WARM HOMES HEALTHY PEOPLE SURVEY
How Did The Client Hear About Us?
Date
Title
Mr 
Mrs 
Miss 
First Name
Surname
DOB
Age
Ms 
Other:
Contact Name (if different to client) & Relationship to client
Telephone No
Email
Local Authority
Address
Town
Postcode
County
Type of property:

House

Bungalow

Flat

Maisonette

Detached

Semi-Detached

Mid Terrace

End-Terrace

Park Home

Bedsit

Owned / Buying on Mortgage

Rented – Private* must provide LL details if a
referral is made regarding the property.
*Landlord Name:
Address:
Telephone:
Email:
Notes:
Number of Storeys:
Number of bedrooms:
Pre-1920
Approximate year of construction:
Type of Wall:

Solid wall

1920 – 1945
Timber frame
1946 – 1979
 Cavity – Insulated
Post 1979
 Cavity – Un-insulated

Other (e.g. system built, park home) State………………………………………………………………………
Client would like to be referred for wall insulation survey: 


Cavity Wall Insulation Referral
Solid Wall Insulation Referral
Loft:
Type of Insulation: ……………………………………………………………………………………..
Depth of existing loft insulation: ………………………………………………………………………..
(NB we will only consider a top up if existing is 100mm (4 inches) or under)
Client would like to be referred for a loft insulation survey: 
Is the client able to arrange for the loft to be cleared? (Can friends, family help?) Y / N
If no would the client like a referral to Lofty Heights for help to clear the loft? Y / N
Can the client pay for this? (funding may be available from WHHP if client is eligible) Y / N
Is there access via a Loft Hatch? Y / N
Is there a loft ladder? Y / N
Page 1 of 4
Nov 2016 Warm Homes Healthy People Energy Survey Form Version 9.
Type of Doors & Windows
 Wooden
 UPVC
 Metal
 Single Glazed
 Double Glazed
Draught proofing required (It is not possible to re-fit UPVC draught seals under this scheme)
Measure
Quantity
Colour
Can client install- Y/N Provided Y/N
Letter box seal
 Brown
 White
Door seal
 Brown
 White
Window foam
 Brown
 White
Radiator Panels
 One box only
Chimney
Balloons
Loft hatch cover
 S 38x23cm, 15”x 9”  M 60x30cm 24”x12”
 L 90x38cm 36”x15”
 Square  Rectangle
Hot water
cylinder jacket
Pipe Lagging
 36” x 18”
 42” x 18”
Main heating supply

Gas (Mains)

Electricity (On peak)

Coal / Smokeless / Similar

LPG / Calor / Bottled

Electricity (Off-peak)

Wood

Oil
 Client would like more information on Community Buying Oil scheme

Client would like information on Fuel Tariff Switching

There is NO gas at or near the property
What is the main heating system?

Boiler and Radiators

Warm Air System

Room Heaters

Under-floor Heating

Other
Storage Heaters


Boiler / Heating repair required (client needs to obtain written estimate)

Boiler replacement (client needs to obtain two written estimates if boiler is beyond repair and these
need to identify why the boiler is beyond repair)
Boiler (Additional information)
Boiler Manufacturer
 Combination
Model Number
 Combination – Condensing
 Normal (with hot water tank)
 Back boiler
What types of heating controls are there?

Timer / Programmer

Room thermostat
Install Date
 Condensing (with hot water tank)

TRVs
Room Heaters Additional information. How many of each?

Gas fire

Gas fire (back boiler to hot water cylinder)

Gas fire (Decorative in fireplace)

Open fire

Closed room heater stove

Open fire (back boiler to hot water cylinder)

Closed room heater (back boiler etc.)

Electric heaters
What type of secondary heating is there?

Gas fire

Gas fire (LPG)

Closed room heater stove (solid fuel)

Open fire

Electric heaters

None
Page 2 of 4
Nov 2016 Warm Homes Healthy People Energy Survey Form Version 9.
How is the hot water heated?

From main heating

Back boiler

From secondary heating

Multi-point Gas Heater

Single-point Gas Heater

Instant electric

Electric Immersion (Off Peak)

Electric Immersion (On Peak)
If the house has a hot water cylinder describe the insulation?

No insulation

Solid foam

Thin jacket
Smoke Alarms
Are smoke alarms present at the property? Y / N


Thick jacket
Client would like a referral to the fire service
Additional Information
Eligibility – Surviving Winter Payment / Grant contribution calculator
House Type
No of beds
Disability
Financial
Fuel Type
Health
Other
SemiDetached= 2
Bedsit = - 3
Means tested benefit
=3
Oil = 4
Terminal
illness = 4
Solid Wall = 2
End terrace=
2
1 Bed = - 2
Physical
Disability – Non
mobile = 3
Limited physical
mobility = 2
Fuel debt = 2
LPG = 3
Child(ren) < 5
=2
Detached=2
2 Bed = - 1
Mental health
illness = 2
Solid Fuel
=3
Flat = 1
3 + Bed = 0
Dual Sensory
loss = 2
Spending 10% or
more of income on
fuel = 2
Low income under
£16,000 = 1
Cardio
vascular
disease = 3
Respiratory
disease = 3
Other debt = 1
Gas = 1
Mid-Terrace=
1
Learning
disability = 1
Sensory
impairment =1
Client Score =……
0 – 4 = 0%
5 – 8 = 0%
9 – 12 = 25%
13 -14 = 50%
15+ = 75%
15+
Electric = 2
Arthritis or
rheumatism
=3
Recent fall =
3
Diabetes = 2
Poor loft
insulation <
150mm = 2
Partial heating
=2
Received fuel
payment last
year = -2
Completed
money
management
course
Fuel Payment
£0
£25
£75
£100
£125
500L (oil only)
Page 3 of 4
Nov 2016 Warm Homes Healthy People Energy Survey Form Version 9.
Only complete eligibility criteria below if client requires assistance from WHHP with funding for measures or if
recommending referral for ECO assessment.
Eligibility Criteria
Client must satisfy one financial and one other criterion:
Financial
Evidence must be checked if funding for
measures is being requested
 Household Annual Income £17,000 or under
 Bank statement checked
 Spending more then 10% of income on fuel bills
 Payslips checked
 In substantial debt with fuel provider
 Utility bill checked – Debt £………
 Benefit award letter checked
Income £……………..
& Fuel Bill £………………………………….
In receipt of a means tested benefit, tick relevant boxes below
 Income Support
 Housing Benefit
 Income Based Job Seekers Allowance
 Working Tax Credit (income under £15,850)
 Child Tax Credit (income under £15,850)
 Disabled Persons Tax Credit
 Guarantee Credit element of Pension Credit
 Income Based Employment Support Allowance
 Other, please state
 No Benefits
Other Criteria
 Aged over 65
 Child(ren) under 5
Health / Disability
 Physical Disability – Non mobile
 Limited physical mobility – uses walking
aids
 Mental health illness
 Receiving Disability Living Allowance
 Learning disability
 Cardio vascular disease
 Respiratory disease
 Receiving Attendance Allowance
 Arthritis or rheumatism
 Recent fall (within the
last 6 weeks)
 Terminal illness
Have you claimed your Warm Homes Discount?
Yes / No. If No, call the Helpline Tel: 03456 039439
Have you claimed your Winter Fuel Payment?
Yes / No. If No, call the Helpline Tel: 03459 151515
If you need further help and are aged over 63 on 01//11/16 please call Citizens Advice Tel: 01473 219770
Homeshield Referral Form completed
Yes / No
I have served in the armed forces and I’m aged over 75 or on means tested benefits and I would like a free
household check by the British Legion
Yes /No
Oil filled loan radiator required
Yes / No
Left with client Yes / No
Radiator number____
My details will be held by Suffolk Coastal District Council (SCDC) as administrator for the Warm Homes Healthy People
project. SCDC is registered under the Data Protection Act 1998. The information provided will be used to determine my
eligibility under this and other current schemes. My details may be passed to other organisations working on this project.
In particular my personal data (name, address and contact details) will be collected and stored for the purposes of
administering and monitoring the Health Improvement Programme by Suffolk Coastal District Council and NEA, a
registered national charity. NEA’s Research Team will be contacting households that have benefitted from this heating
and insulation scheme for the purposes of evaluation. NEA is registered with the Data Commissioner and your personal
details will be treated in the strictest confidence and in accordance with the Data Protection Act 1998. NEA may share
your personal data with its evaluation partner Newcastle University. NEA and Newcastle University will NOT share your
personal details with any other organisations. If you do not want your data to be used in this way for the purpose of
evaluation please tick this box: □ If you have any concerns about this please contact the NEA Research Team on 0191
2692918 or [email protected]
Please tick if you consent to this statement. If you do not tick this box we may be unable to provide you with all
the assistance available.
Customer Signature…………………………
………………. Date …………………………………………………….
Surveyor Signature………………………….
………………. Surveyor Name……………………..........................
NB: If the form is not fully completed it will be rejected
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Nov 2016 Warm Homes Healthy People Energy Survey Form Version 9.