Client Questionnaire HDR

• Site conducted

  Select

• Reference Number

• Do you give permission for images of your property to be disclosed to the landlord?

  Yes

  No

• Title

• Name

• Proof of identity

  Media
• Address
  Address

• Proof of address

  Media

• Mobile number

• Mobile phone provider

• Email address

• National Insurance Number

• Date of birth

• Occupation

• Nationality

• First language

• Other languages spoken

• Do you need someone to help you with English?

  Yes

  No

• Name of translater

• Phone number of translator

• Email address of translator

• Is it a joint tenancy?

  Yes

  No

• Name of joint tenant

• Proof of identity

  Media

• Proof of address

  Media

• Email address

• Telephone number

• NI number

• Date of birth

  Date

• Occupation

• Nationality

• First language

• Other languages spoken

• Have you ever discussed these issues with another solicitor, claims management company or the Housing Ombudsman?

  Yes

  No

• What was the outcome?

• Quality Control Summary following case review

• Qualification Criteria

  Select Secure tenancy Reporting history Arrears within tolerance

  • Secure tenancy
  • Reporting history
  • Arrears within tolerance

• Is your landlord

  Private landlord

  Housing Association

  Council

• Have you been placed in this accommodation under license by your Council or Housing Association?

  Yes

  No

• Name of landlord

• Address of landlord

• Name of Council / Housing Association

• Address of Council / Housing Association

• Please send us a copy of your tenancy agreement. If you are unable to do so we will not be able to help

  Media

• Name of Landlord

• Address of Landlord

• Yes

  No

• When did your tenancy agreement start? (Month/Year)

• Are you in temporary accommodation?

  Yes

  No

• Please supply a copy of your tenancy agreement

  Media

• Have you been offered a permanent tenancy at another property since your tenancy at this property began that you did not take?

  Yes

  No

• Did you acquire the property as part of a house swap or property exchange

  Yes

  No

• Have you been in the property over a year?

  Yes

  No

• Please provide tenancy agreement before proceeding

  Media

• Is it a fixed term tenancy agreement?

  Yes

  No

• When does it end? (Month/Year)

• Please provide a copy of your tenancy agreement

  Media

• You are unable to make a claim for the first year in a house swap situation please park until the year is up

• How much is rent on the property?

• Do you receive help towards the rent from any benefit

  Yes

  No

• Which do you receive currently

  Housing Benefit

  Universal Credit

• Proof of benefits received

  Media

• Do you contribute towards your rent?

  Yes

  No

• How much do you pay per month towards the rent?

• Is this paid a month in arrears?

  Yes

  No

• Do you pay the rent a month in arrears?

  Yes

  No

• Are there any arrears on the rental account currently?

  Yes

  No

• How much are the arrears currently?

  Under £500

  £500-£1000

  £1000+

• Please specify amount

• Do your rent arrears form part of an official debt management order?

  Yes

  No

• Do you have an arrangement to pay?

  Yes

  No

• How much do you pay, in addition to any normal rent contribution towards your arrears each month?

• Are you disputing the arrears?

  Yes

  No

• How did the arrears come about?

• What is the basis for dispute?

• Do you have any correspondence, letters, emails, bills, bank statements etc. that detail and/or support your dispute. This could be a bill for additional charges, statements from Universal Credit about their liability for rent following a move from Housing Benefit, or any other relevant evidence. Please attach

  Media

• Have you ever been made bankrupt?

  Yes

  No

• Please give details including dates

• Please give contact details of the Trustee in Bankruptcy as their permission is required to send the letter of claim.

The Problems in your home

• When was the FIRST time you reported any of problems in your home that to this date has not been effectively repaired and that you are reporting to us today. (Month/Year).

• What did you report at that time?

• When was the MOST RECENT time you reported problems in your home to the landlord? (Month/Year).

• Was that by phone, email, text or in person?

• How many times have you reported in total?

• What rooms in your house are affected by disrepair?

  Select Bathroom Kitchen Living room Dining room Hallway Seperate toilet Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Bedroom 5 Utility room Whole property Outside

  • Bathroom
  • Kitchen
  • Living room
  • Dining room
  • Hallway
  • Seperate toilet
  • Bedroom 1
  • Bedroom 2
  • Bedroom 3
  • Bedroom 4
  • Bedroom 5
  • Utility room
  • Whole property
  • Outside

• When was the last time a representative of your landlord visited your property for any reason

• What was the purpose of that visit?

• Please tick this box if there is an infestation in the property

• If there is only an infestation and NO ADDITIONAL DISREPAIR, please proceed to page 5. Page 6 does not need to be completed.

• Please tick this box if there is disrepair in the property (unrelated to any infestation)

• If there is an infestation AND ADDITIONAL DISREPAIR, please complete infestation section on page 5 AND page 6 as normal

• Is anyone in your home considered vulnerable due to health or other reasons?

  Yes

  No

• What is the nature of that vulnerability?

• Do you have a support worker

  Yes

  No

• Do you do your own banking withouth help from a support worker or relative?

  Yes

  No

• What is the name of the nominated person or individual with Power of Attorney

• Telephone number of nominated individual

• Are you responsible for paying your own bills without support or relative?

  Yes

  No

• What is the name of the nominated person or individual with Power of Attorney

• Telephone number of nominated individual

• This next question is really important as it is the client's story, just type it as you are told it

• Client's version of events / description of damage and effect on occupants - Client story.

• Have the issues complained about affected your ability to use and enjoy the property?

  Yes

  No

  Unsure

• Have the issues prevented you from having visitors?

  Yes

  No

• Have the issues complained about affected your, or other occupants permanently residing at the property, physical or mental health?

  Yes

  No

• Please provide detail of who and the problems suffered?

• Is there any dispute (other than regarding arrears) or pending legal action that may affect your relationship with your landlord?

  Yes

  No

• Tell us about what is happening

• The purpose of this section is to understand potential issues in the property and to help in vetting

• When you moved in, did your landlord provide you with any of the following?

  Select Information on how to set the hot water Information on how to work the heating Information on how to bleeding radiators Information on using window vents Information on using extractor fan and maintenance No information given

  • Information on how to set the hot water
  • Information on how to work the heating
  • Information on how to bleeding radiators
  • Information on using window vents
  • Information on using extractor fan and maintenance
  • No information given

• Does your landlord undertake an annual boiler / gas safe inspection?

  Yes

  No

• When did the last one take place? (Month / Year)

• Does the engineer work directly for the landlord or does an independent contractor attend?

  Select Employed directly by landlord Independent engineer sent by landlord

  • Employed directly by landlord
  • Independent engineer sent by landlord

• Does your landlord undertake an annual condition check of the property?

  Yes

  No

• When did the last check take place? (month/year)

• Have any major works, upgrades or improvements been made to your property by the landlord in the last 6 years?

  Select New roof Taken down chimney Repair / replace gutters, fascias, soffits New windows New external doors New kitchen New bathroom Painted exterior of property Repaired/replaced render New / upgraded loft insulation Addition of Exterior wall insulation Addition or removal of cavity wall insulation Addition or removal of exterior cladding No major works

  • New roof
  • Taken down chimney
  • Repair / replace gutters, fascias, soffits
  • New windows
  • New external doors
  • New kitchen
  • New bathroom
  • Painted exterior of property
  • Repaired/replaced render
  • New / upgraded loft insulation
  • Addition of Exterior wall insulation
  • Addition or removal of cavity wall insulation
  • Addition or removal of exterior cladding
  • No major works

• Please provide details including dates

• Have walls, ceilings or floors in your home ever been tested for asbestos

  Yes

  No

• When was this (month / year)

• What were the results / findings?

• Do you have a copy of the results / report or correspondence from your landlord detailing those findings?

  Yes

  No

• Please provide copy

  Media

• Was any work undertaken on the property as a result of the tests?

  Yes

  No

• When was this (month/year)

• What work was undertaken?

• Has a surveyor (not inspector) visited your property in the last 6 years with a view to reporting back to the landlord on repairs required at your property?

  Yes

  No

• When was this (month / year)

• What were the results / findings?

• Do you have a copy of the results / report or correspondence from your landlord detailing those findings?

  Yes

  No

• Please provide copy

  Media

• Was any work undertaken on the property as a result of the tests?

  Yes

  No

• When was this (month/year)

• What work was undertaken?

• What was the outcome

  Solved problem entirely

  Improved situation

  Had no impact

  Made situation worse

• Has an independent damp or mould specialist visited your property in the past 6 years with a view to reporting back to the landlord on repairs required at your property?

  Yes

  No

• When was this (month / year)

• What were the results / findings?

• Do you have a copy of the results / report or correspondence from your landlord detailing those findings?

  Yes

  No

• Please provide copy

  Media

• Was any work undertaken on the property as a result of the tests?

  Yes

  No

• When was this (month/year)

• What work was undertaken?

• What was the outcome

  Solved problem entirely

  Improved situation

  Had no impact

  Made situation worse

• Has any other kind of independent specialist visited your property in the last 6 years with a view to reporting back to the landlord on repairs required at your property?

  Yes

  No

• What did they come to investigate?

• When was this (month / year)

• What were the results / findings?

• Do you have a copy of the results / report or correspondence from your landlord detailing those findings?

  Yes

  No

• Please provide copy

  Media

• Was any work undertaken on the property as a result of the tests?

  Yes

  No

• When was this (month/year)

• What work was undertaken?

• What was the outcome

  Solved problem entirely

  Improved situation

  Had no impact

  Made situation worse

• The purpose of this section is to find out if the client is contributing in any way to the condition of their property. It will also help inform cause and in establishing a pattern of disrepair.

• What kind of property do you live in?

  Select Terraced house Semi-detached house Detached house Flat - Top floor Flat - mid floor Flat - ground floor Maisonette Bungalow

  • Terraced house
  • Semi-detached house
  • Detached house
  • Flat - Top floor
  • Flat - mid floor
  • Flat - ground floor
  • Maisonette
  • Bungalow

• Are you located at the end of the block with three external walls?

  Yes

  No

• Please provide photos of front back and side of property (ground to sky)

  Media

• Please provide external photos of the front back and side of your property (ground to sky)

  Media

• Please provide external photos of your property (ground to sky)

  Media

• Please provide external photos of the front back and side(s) of your property (ground to sky)

  Media

• What floor are you on?

• What rooms do you have in your home?

  Select Bathroom Kitchen Living room Dining room Hallway Seperate toilet Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Bedroom 5 Utility room Whole property Outside

  • Bathroom
  • Kitchen
  • Living room
  • Dining room
  • Hallway
  • Seperate toilet
  • Bedroom 1
  • Bedroom 2
  • Bedroom 3
  • Bedroom 4
  • Bedroom 5
  • Utility room
  • Whole property
  • Outside

• Do you have an infestation in your home?

  Yes

  No

• What kind of infestation

  Select Mice Rats Bugs

  • Mice
  • Rats
  • Bugs

• What kind of bugs?

• When did you first notice the infestation?

• How are the bugs or rodents entering the property?

• Has the presence of the infestation changed the way you live an behave within your property?

  Yes

  No

• What has been the effect of the infestation on the way you live in the property?

• Has the presence of the infestation had any impact on the physical or mental health of anyone living within the property?

  Yes

  No

• Please detail the health impacts

• How did you notice the infestation was there?

  Select Droppings Gnawing and chewing of property Saw them Heard them

  • Droppings
  • Gnawing and chewing of property
  • Saw them
  • Heard them

• Where did you hear them?

  Select Walls Ceiling Loft Moving about the property

  • Walls
  • Ceiling
  • Loft
  • Moving about the property

• Where was this?

  Select Bathroom Kitchen Living room Dining room Hallway Seperate toilet Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Bedroom 5 Utility room Whole property Outside

  • Bathroom
  • Kitchen
  • Living room
  • Dining room
  • Hallway
  • Seperate toilet
  • Bedroom 1
  • Bedroom 2
  • Bedroom 3
  • Bedroom 4
  • Bedroom 5
  • Utility room
  • Whole property
  • Outside

• Please describe activity within the home over the last 5 days (bullet points day by day)

• Did you report to

  Select Council Environmental Health Neither

  • Council
  • Environmental Health
  • Neither

• Why did you not report it?

• When did you report it?

• How did you report it?

  Phone

  Email

  Writing

• How many times have you reported it?

• Do you have any evidence of these complaints?

  Yes

  No

• Was pest control sent to the property?

  Yes

  No

• Who did the pest controller work for?

  Council

  Housing Association

  Environmental Health

  Private contractor

• The Pest controller will have left you paperwork. What paper-work did they leave you?

  Select Leaflet about infestations Information on the steps taken in the home Contact information for the pest controller Appointment card for next visit Full infestation report

  • Leaflet about infestations
  • Information on the steps taken in the home
  • Contact information for the pest controller
  • Appointment card for next visit
  • Full infestation report

• PLEASE PROVIDE PHOTO OF ANY PAPERWORK OR DOCUMENTATION LEFT AT THE PROPERTY.

  Media

• Did the pest controller say that there would be another visit to check if the treatment had been successful?

  Yes

  No

• How long did they say it would be before another visit?

  One week

  Two weeks

  One month

  Three months

  Other

• Did the pest controller return as planned?

  Yes

  No

• When did you report to your landlord that the pest control had been unsuccessful?

• Are there any plans in place to send pest control out again?

  Yes

  No

• How many times has the cycle of pest control been completed?

• What method (s) of pest control were attempted?

  Select Poison Traps Fumigation Spray Rat paper

  • Poison
  • Traps
  • Fumigation
  • Spray
  • Rat paper

• Did you notify the landlord that the pest controller did not return?

  Yes

  No

• Did you request another visit from pest control

  Yes

  No

• Have you reported the infestation to your landlord since 1st April 2020

  Yes

  No

• Please ask the tenant to report again in writing and put the case in park.

• When was this?

• How did you report it?

  Phone

  Email

  Writing

• Did the landlord offer to rectify the problem free of charge?

  Yes

  No

• What action did the landlord take to prevent further infestation? (includes filling holes, repairing chewed walls, floors, flooring and skirtings with suitable material and making good, taking out kitchen cabinets or bathroom furniture or other fixtures and fittings around suspected entry points)

• Has the landlord sanitised the property and replaced any items damaged by the infestation?

  Yes

  No

• Do you leave perishable food out on work surfaces

  Yes

  No

• Please provide photos of work surfaces

  Media

• Do you wash your dishes on a daily basis?

  Yes

  No

• Would you consider yourself a hoarder?

  Yes

  No

• Do you keep your home in a reasonably clean and tidy condition?

  Yes

  No

• Please provide whole room photos of all rooms where there is infestation activity

  Media

• Does your indoor bin have a secure lid?

  Yes

  No

• Do you put your bin bags in a wheelie bin with the lid securely closed?

  Yes

  No

• Have you been provided with a wheelie bin?

  Yes

  No

• Please provide photos of external and internal rubbish storage

  Media

• Do you leave stagnant water outside your house? (eg bird baths, dog bowls, swimming pools)

  Yes

  No

• Do you leave any perishable food outside (eg dog food bird food etc)

  Yes

  No

• Please provide photos of your garden

  Media

• Do you have decking in your garden?

  Yes

  No

• Was it there when you moved in?

  Yes

  No

• Did you get permission to install it?

  Yes

  No

• When was it installed?

  Yes

  No

• Please provide images of the decking

  Media

• Do you consider ceiling or wall cracks to be a significant issue in your home?

  Yes

  No

• Did the crack form as part of a leak?

  Yes

  No

• Is there still water coming through the crack?

  Yes

  No

• Does the crack form part of a bulge on the ceiling?

  Yes

  No

• Is the crack big enough to fit a pound coin into?

  Yes

  No

• Is it on an external wall?

  Yes

  No

• Is there a / are there corresponding crack(s) on the outside of the property?

  Yes

  No

• What room(s) does this affect?

  Select Bathroom Kitchen Living room Dining room Hallway Seperate toilet Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Bedroom 5 Utility room Whole property Outside

  • Bathroom
  • Kitchen
  • Living room
  • Dining room
  • Hallway
  • Seperate toilet
  • Bedroom 1
  • Bedroom 2
  • Bedroom 3
  • Bedroom 4
  • Bedroom 5
  • Utility room
  • Whole property
  • Outside

• Do you consider black, white, yellow, pink or grey mould, damp, leaks or water entering the property to be a significant problem in your home? 2sqm or more.

  Yes

  No

• Has the mould formed or significantly worsened following an escape of water such as a leak

  Yes

  No

• Has there been more than one such leak?

  Yes

  No
Leaks

• What was the source of the leak?

• When did you report it?

• Has the landlord attempted a repair?

  Yes

  No

  Don't know

• Has the water stopped flowing?

  Yes

  No

• What do you think might be the reason for that?

• When did you let the landlord know that the repair had been unsuccessful

  Yes

  No

• When was it repaired (Month / Year)

• Once it was fixed has it recurred, requiring a further fix?

  Yes

  No

• How many times has a permanent fix been attempted

• Has it now been permanently fixed in your view?

  Yes

  No

• When did you report that the fix had been unsuccessful? (Month / Year)

• Do you think the leak might be intermittent?

  Yes

  No

  Don't know

• What room or rooms are affected?

  Select Bathroom Kitchen Living room Dining room Hallway Seperate toilet Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Bedroom 5 Utility room Whole property Outside

  • Bathroom
  • Kitchen
  • Living room
  • Dining room
  • Hallway
  • Seperate toilet
  • Bedroom 1
  • Bedroom 2
  • Bedroom 3
  • Bedroom 4
  • Bedroom 5
  • Utility room
  • Whole property
  • Outside

• What was the source of the leak?

• When did you report it?

• Has the landlord attempted a repair?

  Yes

  No

  Don't know

• Has the water stopped flowing?

  Yes

  No

• What do you think might be the reason for that?

• What room or rooms are affected?

  Select Bathroom Kitchen Living room Dining room Hallway Seperate toilet Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Bedroom 5 Utility room Whole property Outside

  • Bathroom
  • Kitchen
  • Living room
  • Dining room
  • Hallway
  • Seperate toilet
  • Bedroom 1
  • Bedroom 2
  • Bedroom 3
  • Bedroom 4
  • Bedroom 5
  • Utility room
  • Whole property
  • Outside

• When was it repaired (Month / Year)

• Once it was fixed has it recurred, requiring a further fix?

  Yes

  No

• How many times has a permanent fix been attempted

• Has it now been permanently fixed in your view?

  Yes

  No

• Do you think the leak might be intermittent?

  Yes

  No

  Don't know

• Was there any other change such as new windows, insulation, work done on the house etc. that immediately preceded or led to the problems?

  Yes

  No

• What was the change?

• Have you ever had a prolonged period without heating?

  Yes

  No

• How long were you without heating?

• When was this?

• Did you report it?

  Yes

  No

• When did you report it?

• Did your landlord repair it?

  Yes

  No

• Are you still without heating?

  Yes

  No

• How was it resolved?

• Was the repair successful?

  Yes

  No

• When did you report that the repair was unsuccessful?

• When were the extractor fans installed in your property?

• There are extractor fans present in which rooms

  Select Kitchen Bathroom Other

  • Kitchen
  • Bathroom
  • Other

• Are any of the extractor fans not working / not working properly?

  Select Kitchen Bathroom Other N/A - All working

  • Kitchen
  • Bathroom
  • Other
  • N/A - All working

• Have you reported failure of extractor fan(s)?

  Yes

  No

• Do you have a tumble dryer?

  Yes

  No

• Is the condensing kind or the type with a pipe?

  Condensing

  Pipe exhaust

• What room is it kept in?

  Select Bathroom Kitchen Living room Dining room Hallway Seperate toilet Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Bedroom 5 Utility room Whole property Outside

  • Bathroom
  • Kitchen
  • Living room
  • Dining room
  • Hallway
  • Seperate toilet
  • Bedroom 1
  • Bedroom 2
  • Bedroom 3
  • Bedroom 4
  • Bedroom 5
  • Utility room
  • Whole property
  • Outside

• Is there black mould in that room?

  Yes

  No

• Briefly, where is that black mould

• When it's not possible to dry washing outside where do you dry it? (Please select all that apply)

  Select Bathroom Kitchen Living room Dining room Hallway Seperate toilet Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Bedroom 5 Utility room Whole property Outside

  • Bathroom
  • Kitchen
  • Living room
  • Dining room
  • Hallway
  • Seperate toilet
  • Bedroom 1
  • Bedroom 2
  • Bedroom 3
  • Bedroom 4
  • Bedroom 5
  • Utility room
  • Whole property
  • Outside

• Is there black mould growth in this room?

  Yes

  No

  Don't know

• Is your heating / hot water system currently in working order

  Yes

  No

• Do you feel the problem is with

  Select The boiler One or more radiators Pipes Other

  • The boiler
  • One or more radiators
  • Pipes
  • Other

• What do you think is the problem?

• On your boiler is there a problem with

  Select Pressure Leak Failure of water to heat up Failure of radiator(s) to fully heat Other Noise None of these

  • Pressure
  • Leak
  • Failure of water to heat up
  • Failure of radiator(s) to fully heat
  • Other
  • Noise
  • None of these

• When were the radiators last bled?

• When you bled the radiators, what came out?

  Select Air only Air and clear water Air and white water Air and black water Air and sludge Just clear water Just white water Just black water Just sludge

  • Air only
  • Air and clear water
  • Air and white water
  • Air and black water
  • Air and sludge
  • Just clear water
  • Just white water
  • Just black water
  • Just sludge

• Has the pressure relief valve been adjusted (metal hose underneath the boiler with water valves either end)

  Yes

  No

• Are any of the radiators or hot water pipes leaking

  Yes

  No

• Have you reported it?

  Yes

  No

• When did you report it?

• Has your landlord made arrangements to repair

  Yes

  No

• When are they coming to repair it?

• Are your electrics in full working order?

  Yes

  No

• Do you feel the problem is with

  Select Damage following a leak Damage following an installation of an appliance Other

  • Damage following a leak
  • Damage following an installation of an appliance
  • Other

• What do you think is the cause?

• Describe the problem including room(s) affected, what exactly doesn't work

• Have you reported it?

  Yes

  No

• When did you report it?

• Has the landord ever attempted any repairs / work arounds, or offered any advice?

  Yes

  No

• Please describe works done or advice given

• With the exception of any leaks previously mentioned, Is your water / sanitary / plumbing in full working order?

  Yes

  No

• What problems are you experiencing?

  Select Knocking pipes Whining noises Problems with grey water draining Problems with foul water draining Leaking pipes / radiators Other

  • Knocking pipes
  • Whining noises
  • Problems with grey water draining
  • Problems with foul water draining
  • Leaking pipes / radiators
  • Other

• What room(s) are affected by this?

  Select Bathroom Kitchen Living room Dining room Hallway Seperate toilet Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Bedroom 5 Utility room Whole property Outside

  • Bathroom
  • Kitchen
  • Living room
  • Dining room
  • Hallway
  • Seperate toilet
  • Bedroom 1
  • Bedroom 2
  • Bedroom 3
  • Bedroom 4
  • Bedroom 5
  • Utility room
  • Whole property
  • Outside

• Please describe

• What type of windows do you have in the property?

  Select Opening casements Vertical sliding sash Bi-fold Combination of styles Not known

  • Opening casements
  • Vertical sliding sash
  • Bi-fold
  • Combination of styles
  • Not known

• Do they rattle loudly?

  Yes

  No

• Are any of the windows broken or have any broken elements

  Yes

  No

  Unsure

• Briefly is the damage

  Select Water / draught entering property from gap between frame and window surround Perished seals between glazing and frame due to build up of condensation Broken lock or handle Failure to fully close / lock Can't open

  • Water / draught entering property from gap between frame and window surround
  • Perished seals between glazing and frame due to build up of condensation
  • Broken lock or handle
  • Failure to fully close / lock
  • Can't open

• What rooms does this affect?

  Select Bathroom Kitchen Living room Dining room Hallway Seperate toilet Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Bedroom 5 Utility room Whole property Outside

  • Bathroom
  • Kitchen
  • Living room
  • Dining room
  • Hallway
  • Seperate toilet
  • Bedroom 1
  • Bedroom 2
  • Bedroom 3
  • Bedroom 4
  • Bedroom 5
  • Utility room
  • Whole property
  • Outside

• In the rooms causing concern do the windows have trickle vents to let air in?

  Yes

  No

  Don't know

• Are the trickle vents in full working order?

  Yes

  No

• Have you reported this?

  Yes

  No

• How often do you keep them open?

• Has the disrepair in your home caused you to spend more than expected on gas or electricity

  Yes

  No

  Unsure

• Please give details and additonal cost per month

• In order, of date reported please complete the information about each of the rooms / areas in the property. For the room that has already been documented, please click "worst room" complete the repairs information and move on to the next reported problem.

• Click + to add a room or area with damage

• If a single problem such as heating or electrical failure is affecting the whole property choose "whole house".

Room / Area damaged

• Name of room / area

  Select Bathroom Kitchen Living room Dining room Hallway Seperate toilet Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Bedroom 5 Utility room Whole property Outside

  • Bathroom
  • Kitchen
  • Living room
  • Dining room
  • Hallway
  • Seperate toilet
  • Bedroom 1
  • Bedroom 2
  • Bedroom 3
  • Bedroom 4
  • Bedroom 5
  • Utility room
  • Whole property
  • Outside

• Is there an extractor fan installed in this room?

  Yes

  No

• Is it fully functioning?

  Yes

  No

• How long has it been out of action?

• Has it been serviced in the last year?

  Yes

  No

• Where is this room located in the property? (please click ALL that apply eg Back Left)

  Select Front Side Rear Left Right Central

  • Front
  • Side
  • Rear
  • Left
  • Right
  • Central

• Is it upstairs or downstairs in the property (if flat or bungalow click "single level")?

  Upstairs

  Downstairs

  Single level

• Exterior image showing this room

  Media

• Description of damage to this area including location, size of damaged area, proximity to other affected rooms/areas and nature and experience of problem eg temperature variance, smell, feel etc

• Photos of internal damage including WHAT, HOW MUCH and WHERE the damage is

  Media

• When did you first report the damage in this room?

• Additional relevant information

• Has a representative of the landlord been out to assess?

  Yes

  No

• What did they do/say?

  Select Take photos Examine property Clean / sanitise Promise repairs Gave advice on reducing condensation Other

  • Take photos
  • Examine property
  • Clean / sanitise
  • Promise repairs
  • Gave advice on reducing condensation
  • Other

• Please give details

• Have you informed the landlord since this was done that the problem has returned?

  Yes

  No

• When was this? (month / year)

• Have they assessed this problem more than once?

  Yes

  No

• How many times have they assessed this problem?

• Are there any other issues that we've previously detailed that affect this room?

  Select Problems with electrics Failure of heating Failure of hot water Other N/A

  • Problems with electrics
  • Failure of heating
  • Failure of hot water
  • Other
  • N/A

• Please provide details

• Excluding those detailed in a previous section of the questionnaire (leaks) has the landlord ever attempted repairs to this area?

  Yes

  No

• Click + to add a repair. Please add them in date order

Repairs made by landlord

• Date (month / year)

• Nature of repairs

  Select Cleaned / sanitised Painting New plaster New ceiling section Repaired flooring Drying room Fix leak Roof repair Window repair Wall / brick repair Install extractor fan Install additional ventilation Other

  • Cleaned / sanitised
  • Painting
  • New plaster
  • New ceiling section
  • Repaired flooring
  • Drying room
  • Fix leak
  • Roof repair
  • Window repair
  • Wall / brick repair
  • Install extractor fan
  • Install additional ventilation
  • Other

• Detail of repair

• What was the outcome of the repair?

  Solved problem entirely

  Improved situation

  Had no impact

  Made situation worse

• When did you tell your landlord that the repair hadn't solved the problem?

• Have YOU ever made repairs to this area?

  Yes

  No

• About repairs YOU have made to this area in DATE ORDER

• Click + to add a repair.

Repairs made by tenant and outcome

• Date (month / year)

• Nature of repairs

  Select Cleaned / sanitised Painting New plaster New ceiling section Repaired flooring Drying room Fix leak Roof repair Window repair Wall / brick repair Install extractor fan Install additional ventilation Other

  • Cleaned / sanitised
  • Painting
  • New plaster
  • New ceiling section
  • Repaired flooring
  • Drying room
  • Fix leak
  • Roof repair
  • Window repair
  • Wall / brick repair
  • Install extractor fan
  • Install additional ventilation
  • Other

• Detail of repair

• What was the outcome of the repair?

  Solved problem entirely

  Improved situation

  Had no impact

  Made situation worse

• How much did you spend on this repair?

• Additional Relevant Photographs

  Media

• Please attach copies of any relevant correspondence with the landlord

  Media

• Has any damage been caused to personal property by the issues complained of? (For example clothing, linen, soft furnishings)

  Yes

  No

  Not sure/ Need to check

• Click + to add details of a loss

Losses

• Description of item

• Date purchased

  Date

• Where purchased

• Price

• Do you have a receipt?

  Yes

  No

• Reason for damage

• PLEASE READ TO CLIENT:
  WE ARE ABOUT TO COMPLETE A DECLARATION CONFIRMING OUR CONVERSATION, A SUMMARY OF DAMAGE TO YOUR PROPERTY AND YOUR CONFIRMATION OF ACCURACY AND TRUTH.
  TO REMIND YOU - CALLS MAY BE RECORDED FOR TRAINING AND QUALITY PURPOSES

• Do you confirm that everything that you have told me today has been true and accurate?

  Yes

  No

• Of the issues we have discussed today that have not been fixed, when was the earliest report made?

• When did you last report this issue?

• You can confirm that we have discussed your whole home including areas which you may not have initially had in mind when you contacted us

  Yes

  No

• You are happy that the damage we have discussed is a true and fair reflection of the condition of your home and the repairs that are necessary to restore your home to a habitable condition?

  Yes

  No

• I confirm that I have understood the notes taken above in respect of my description of housing disrepair claim and instruct my solicitors to commence my housing disrepair claim on the basis of this information.

• Name

• Address

• Signed

  Sign

• Date