Bell Group - PAS 2035 Resident Engagement Questionnaire V1.0

Details

• Conducted on

  Date

• Prepared by

  Nick Phillips

  Lee Glenister

  Adele Stretch

  Other

  Surveyor

• Operative/Surveyor Name

• Client and Tenure

  Select Peaks and Plains Live West Curo Owner Occupier Privately Rented Other

  • Peaks and Plains
  • Live West
  • Curo
  • Owner Occupier
  • Privately Rented
  • Other

• Who?

• Survey Type

  Resident Questionnaire

• First Line of Address

• Front Elevation Photo

  Media

• Date for commencement of work

  Date
• GPS
  Address

Occupant Assessment

• Is the property highlighted as flagged or at risk?

  No

  Yes

• Comments

• How many occupants?

  Select 0 1 2 3 4 5 6 7

  • 0
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7

• How many occupants under the age of 18?

  Select 0 1 2 3 4 5 6 7

  • 0
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7

• Do any of the occupants have any existing medical conditions?

  No

  Yes

• Skin allergies (e.g. eczema)

• Details

• Breathing problems caused by dust (e.g. asthma)

• Details

• Pregnancy

• Details

• Mental health issues or learning difficulties (depression, anxiety, agoraphobia etc)

• Details

• Mobility Issues

• Details

• Other

• Are there any potential risks regarding pets in the property?

  No

  Yes

• Comments

• Is the property high risk of biological waste or vermin?

  No

  Yes

• Comments

• Photographic evidence

  Media

• Is the property at high risk of hypodermic needles?

  No

  Yes

• Comments

• Any other considerations that should be taken into account?

  No

  Yes

• Describe

• Photo

  Media

Resident Questionnaire

• Resident Name

• Resident Contact Details

  Select Home Number Mobile Number Work Number Email Family Member

  • Home Number
  • Mobile Number
  • Work Number
  • Email
  • Family Member

• Home Number

• Mobile Number

• Work Number

• Email Address

• What family member?

• Family Member Telephone Number

• Tenant Contact Preferences

  Select Home Number Mobile Number Work Number Email Family Member

  • Home Number
  • Mobile Number
  • Work Number
  • Email
  • Family Member

• Best Days for Installation / Days to Avoid / Time of Day

• Emergency Contact

• How Much Notice does the resident require?

• Do you have any carers or support workers who visit throughout the day

  Yes

  No

  N/A

• When

• Can we contact them?

  Yes

  No

• Contact Details

• Night/Shift Workers in the Property

  Yes

  No

• Details

• How many occupants are likely to be in the property during normal working hours (8am-5pm Mon-Fri)

• Are you happy to supply a key for access during the work

  Yes

  No

• Access Details: Key holders name and contact details

• Resident Handbook Received

  Yes

  No

• How would you like to be addressed by our representatives

• Please advise resident of the Housing Provider's intentions to improve their home by installing energy efficiency measures listed below. Their home may be installed with all, or some of these measures and further information will be provided once our assessments and surveys have been completed.

• Improvements will: - Reduce energy consumption and running costs - Reduce Carbon Dioxide emissions - Increase comfort and wellbeing - Increase healthy ventilation of the home

Proposed Measures

• Underfloor Insulation

• Cavity Wall Insulation

• External Wall Insulation

• Loft Insulation top up

• Replacement Windows and Doors

• Corrective Ventilation

• Please provide resident with letter/handouts covering the proposed measures and the method statement for the assessments and surveys to be undertaken and confirm this has been done

Assessment Sign off

• Resident Signature and Full Name

  Sign

• TLO Signature and Full Name

  Sign