Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 Page 4 of 4 Nov 2016 Warm Homes Healthy People Energy Survey Form Version 9.