Information
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Conducted on
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Location
Customer Details
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Reference - UPRN needed
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Title
- Miss
- Mr
- Ms
- Mrs
- Dr
- Lord
- Lady
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Forename
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Surname
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Address 1
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Address 2
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Address 3
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Post Code
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Telephone
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Mobile
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Email
Visit Info
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Energy Advisors
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Date/Time of visit
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Build Form - House
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Build Form - Apartment
- Basement
- Ground floor
- 1st Floor
- 2nd Floor
- 3rd Floor
- Top Floor
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Build Form Unknown - Please comment
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Build Form - Bungalow - Please Comment
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Number of Occupants
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 10+
Energy Info
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Do you understand what 'Energy Efficient' means?
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Comment
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What energy saving measures are you using currently in your home?
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Do you consider your home to be cold?
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What type of space heating is used most frequently?
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Main Space Heating Fuel Type
- Gas
- Electric
- Oil
- Wood Burner
- ASHP
- Other - Please Comment
- Biofuel
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Is your boiler working properly at the moment?
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Do you have the instructions to use the heating system?
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If no, would you like a copy?
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Make and model for manual required
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Is any supplementary heating used?
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Do you have any heating controls?
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Programmer
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Is it set to the right times?
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Do you have the instructions to use the programmer?
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If no, would you like a copy?
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Make and model for manual required
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Room thermostat
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If yes, are thermostats for the heating working and set to the right temperature (18-21C)?
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Thermostatic radiator valve?
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What settings are used?
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Do you understand how to operate the TRV?
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Water Heating System
- From space heating
- On peak immersion/cylinder
- Off peak immersion/cylinder
- Gas instantaneous
- Electric instantaneous
- Solar hot water
- Unknown
Damp/Condensation
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Are there any signs of damp/condensation/mould/growth?
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If yes, please where?
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Add supporting image #1
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Add supporting image #2
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Add supporting image #3
Bill Information
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How much do you spend on your Electric bills?
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Payment frequency
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How much do you spend on your Gas bills?
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Payment frequency
- Weekly
- Monthly
- Quarterly
- Half-Yearly
- Annually
- Pre-Payment Meter
- Other
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How much do you spend on Dual Fuel ?
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Payment frequency
- Weekly
- Monthly
- Quarterly
- Half-Yearly
- Annually
- Pre-Payment Meter
- Other
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What is your method of payment?
- Direct Debit
- Standing Order
- Bank/Building Society/Post Office
- Quarterly
- Pre-Payment Meter
- Other - please comment
- Online payments
- PayPoint
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Comment
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Who is your electricity provider?
- British Gas
- Scottish Power
- EDF
- N Power
- EOn
- SSE
- Good Energy
- Ecotricity
- Other - please comment
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Comment
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What is your current tariff?
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Comment
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Who is your gas provider?
- British Gas
- Scottish Power
- EDF
- N Power
- EOn
- SSE
- Good Energy
- Ecotricity
- Other - please comment
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Comment
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What is your current tariff?
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Comment
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Who is your Dual Fuel provider?
- British Gas
- Scottish Power
- EDF
- N Power
- EOn
- SSE
- Good Energy
- Ecotricity
- Other - please comment
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Comment
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What is your current tariff?
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Comment
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Do you understand your bills?
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When did you last switch providers?
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Comment - www.billscutter.com
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Would you like any fuel switching advice?
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Comment
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Are you currently in fuel debt?
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If yes, please comment
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Would you like help to manage your debt?
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If yes, please comment
Prescription with Saving
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Use your programmer, heating controls and TRVs effectively
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Comment
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Microwave ovens use less energy than conventional cookers
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Comment
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Keep room temperatures between 18-21C and reduce by 1C if comfortable
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Comment
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Install radiator panels on outside walls
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Comment
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Don't leave energy appliances on standby
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Comment
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Only boil what is needed in the kettle
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Comment
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Turn off unwanted lights, use energy savings lightbulbs and consider using LEDs
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Comment
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Dry washing outside where possible
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Comment
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When replacing appliances, choose most energy efficient models
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Comment
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Use a Shower Timer to have shorter showers
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Comment
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Use economy or low temp cycles on low appliances, and wait for a full load on wet appliances
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Comment
Prescription with Savings Unknown
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Prevent heat from escaping through gaps in windows or doors with draughtproofing
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Comment
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Keep internal doors closed
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Comment
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Close curtains at dusk
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Comment
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Have showers not baths (unless power shower)
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Comment
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Don't block radiators with clothes, furniture or curtains
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Comment
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Don't leave fridge/freezer door open longer than necessary
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Comment
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Defrost food in Fridge where possible
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Comment
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Use your energy monitor to compare the energy usage of items in your home, and identify where you can save energy
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Comment
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Do you have a Water Meter?
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Comment
Environmental Team
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Would you be interested in visiting an Eco Home?
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Comment
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Would you be interested in becoming an Eco Champion?
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Comment
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How did you hear about the Home Energy Check service?
- Groundwork
- Info at local community centre
- Housing Officer
- Website
- Letter sent out from GPHG
- You Can Glow referral
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Comment
Referrals/Further Advice Given
Further Help
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Finding work or accessing training
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Comment
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Debt Management
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Comment
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Welfare Reform
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Comment
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Aids and Adaptations
Items Received
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Radflek
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 10+
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Comment
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Electricity Monitor
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Date to be collected/returned
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Lightbulb
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 10+
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TV Power-Down
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Shower Timer
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Room Thermometer
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Prescription
Optional Information
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Signature
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Time of departure
