Title Page

  • Conducted on

  • Conducted For (Full Name Inc Title)

  • Title,

  • Client ID No. (HHD)

  • Customer Password

  • Landline Tel No

  • Mobile Tel No

  • Work Tel No

  • Email Address

  • 3rd Party Contact Details (if applicable)

  • 1st Line of Address

  • Property Address
  • Prepared by

Property

  • Property Tenure

  • If Owned - Leasehold / Freehold

  • Landlord/Agent Name

  • Address

  • Telephone Number

  • Email Address

  • Property Type

  • Number Of Bedrooms

  • Property Age

  • EPC Rating - https://www.gov.uk/find-energy-certificate

  • Fuel Type

  • Heating Type

  • Boiler Age (if Applicable)

  • Heating Controls Present:- Room Stat, Programmer, TRV's. (please circle)

  • Photo of Main Heating & Controls

  • Photo of Water Cylinder & Tank Stat (if applicable)

  • Electricity Meter Type (Only if Electric Heating). On-Peak, Off-Peak (please circle)

  • Electric Meter Type

  • Any Renewable Energy Measures Present

  • Please List Measure

  • Any Damp or Mould on Walls or Ceilings

Eligiblity

  • Date Of Birth (dd/mm/yyyy)

  • Benefits/Allowances

  • Benefits/Allowance 1

  • Benefits/Allowance 2

  • Benefits/Allowance 3

  • Health Conditions

  • Health Condition 1

  • Health Condition 2

  • Health Condition 3

  • Resident Over 65

  • Child Under 5

  • Child Date of Birth (dd/mm/yyyy)

  • Resident Pregnant

  • Estimated Household Annual Income

  • Monthly Mortgage/Rent payment

  • Monthly Council Tax Band - https://www.gov.uk/council-tax-bands

  • Does this client fall within local councils low income threshold for Flex Eligibility

  • Armed Forces/Ex-Armed Forces or a Partner of

  • Had a fall and attended hospital recently

  • Addictions

  • Asylum Seeker/Immigrant

  • Moving In or Out of Homelessness

  • Any Other Challenging Circumstances or Hardships - That impact day to day living.

  • Annual Fuel Cost

  • Number of Adults in property

  • Number of Children in property

Measure Required (Loft Insulation)

  • Loft Insulation Required (must be 150mm or Below)

  • Please record Depth

  • Please provide Clear photo of loft depth

  • Is Loft Easy Accessible

  • Depth of existing Loft insulation

  • Please provide Clear photo of loft depth

  • Please provide Clear photo of loft depth

  • Please provide Clear photo of loft depth

  • Please provide Clear photo of loft depth

  • Please provide Clear photo of loft depth

  • Please provide Clear photo of loft depth

  • Please provide Clear photo of loft depth

  • Loft Area m2

  • Will the loft require emptying of belongings

  • Has conversation been had with resident in regards to emptying the loft for install?

  • Will a separate Insulation Survey be required for this Measure?

  • List any notes below

Measure Required (Cavity Wall Insulation)

  • Cavity Wall Insulation Required

  • Property Install Size

  • What is the building condition & access like around property.

  • Can DPC be seen above ground level

  • Will a separate insulation survey be required for this measure?

Other Measures Required or Interested in.

  • External Wall Insulation (Including Single Skin Extensions)

  • M2 of EWI

  • Room In Roof Insulation

  • Is this a qualifying RIR

  • Number of Rooms in RIR

  • Access to Residual Area

  • Does this need Insulation

  • Other areas that require insulation

  • Under Floor Insulation

  • Floor Type

  • Ground floor M2

  • Is there access to the floor void

  • Floor Void Depth

  • Flat Roof Insulation

  • Flat Roof Size M2

  • How Many Rooms with Flat Roof

  • Photo of Flat Roof (From above & Ground level)

  • Broken Boiler

  • Boiler Make & Model

  • Photo of Boiler & Location

  • Gas Central Heating required (FTCH)

  • Is there Gas within 23m of property

  • Is Gas Connection Required

  • Is property fully insulated

  • Which Insulation Measure is required

  • HHR Storage Heaters

  • Existing Meter type

  • Photo of Meter

  • How many HHR Heaters Required

  • Photos of old heaters

  • Any other renewable energy or energy efficiency measures possible

  • Hazard Referrals

  • Any Slips, Trips, & Fall Hazards

  • Has the resident got any property condition concerns

  • Any other debt, feel, water bill, concerns we could refer to CAB or LEAP

  • Any Notes

Referrals required

  • Eco4 Eligible

  • Does Property require both Cavity Wall and or Loft Insulation

  • Will the property qualify for new Heating System

  • Is there a live Gas Connection pre 1st April 2022?

  • Can we upgrade ESH heating

  • Is there an existing EPC on the property

  • Would this Qualify for D-Cap only

  • Would this Qualify for D-cap only

  • Please Complete new EPC and EPR for this property and Upload when complete

  • Why has this not been completed,

  • Please complete EST Consent PRIV & Flex Form with resident

  • Reason Why

  • LEAP (Replacement Appliances + Emergency Heating Replacement)

  • Please send referral information to Surveys@ridgewaterenergy.co.uk

  • CAB

Complete Survey

  • Had you received information from your landlord prior to us attending?

  • I can confirm that I have received a copy of the Terms & Conditions, and that I agree to my information provided in this document being shared within the DESNZ, to help securement of grant funding available.

  • Customer Sign:

  • Completed By

  • Date:

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