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Healthy Homes Dorset - Data Capture survey
Healthy Homes Dorset - Data Capture survey
Steve Bright

Healthy Homes Dorset - Data Capture survey

Data Capture Survey

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Free Healthy Homes Dorset - Data Capture survey Checklist

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Title Page

  • Conducted on

  • Conducted For (Full Name Inc Title)

  • Title,

    • Mr
    • Mrs
    • Miss
    • Ms
    • Dr
    • Reverend

  • 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

    • Dan Browne
    • Steve Bright
    • Peter Bywater
    • Johnny Fox
    • Gavin Byrne
    • Chris Denman

Property

  • Property Tenure

  • If Owned - Leasehold / Freehold

  • Landlord/Agent Name

  • Address

  • Telephone Number

  • Email Address

  • Property Type

    • Detached House
    • Semi House
    • Mid Terrace House
    • End Terrace House
    • Detached Bungalow
    • Semi Bungalow
    • Mid Terrace Bungalow
    • Ground Floor Flat
    • Mid Floor Flat
    • Top Floor Flat
    • Maisonette
    • Single Park Home
    • Double Park Home

  • Number Of Bedrooms

    • 1
    • 2
    • 3
    • 4
    • 5
    • 6+

  • Property Age

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

    • A
    • B
    • C
    • D
    • E
    • F
    • G
    • No EPC

  • Fuel Type

    • Gas
    • Electric
    • LPG Tank
    • LPG Bottle
    • Oil
    • Biomass
    • Solid Fuel

  • Heating Type

    • Conventional Boiler
    • Combi Boiler
    • Condensing Boiler
    • Warm Air System
    • Wall Heaters
    • Storage Heaters
    • HHR Storage Heaters
    • No Main Heating

  • Boiler Age (if Applicable)

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

    • Room Thermostat
    • TRV's
    • Programmer/Timer
    • Smart Thermostat
    • No Heating Controls

  • 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 Dorset or BCP 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

    • 175mm
    • 200mm
    • 225mm
    • 250mm
    • 275mm
    • 300mm
    • 300mm Plus

  • Please provide Clear photo of loft depth

  • Is Loft Easy Accessible

  • Depth of existing Loft insulation

    • 0mm
    • 25mm
    • 50mm
    • 75mm
    • 100mm
    • 125mm
    • 150mm
    • 150mm and Above

  • 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

    • Yes - Borescope check done
    • No - Borescope check Done
    • No - Visible Drill Patten on property
    • No - Customer confirmed not Required
    • No - Solid Wall / Timber Framed

  • 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

    • Pitched Roof
    • Flat Roof
    • Stud Wall
    • Sloping Ceilings
    • Gable/Party Wall
    • Dormer Windows

  • 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

    • CWI
    • Loft
    • Flat Roof
    • RIR

  • 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

    • Boiler - Repair of an Efficient Heating System
    • Boiler - Broken Replacement
    • Boiler - Upgrade of an Inefficient System
    • First Time Central Heating
    • ESH - Repair or Replacement
    • ESH - Replacement of a broken efficient
    • ESH - Upgrade of an inefficient Heater
    • ASHP - Electric heating Only
    • Solar PV - Electric heating Only

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

  • Can we upgrade ESH heating

  • Is there an existing EPC on the property

    • High D 61.5 - 68.4
    • Low D 54.5 - 61.4
    • High E 46.5 -54.4
    • Low E 38.5 - 46.4
    • High F 29.5 - 38.4
    • Low F 20.5 -29.4
    • High G 10.5 - 20.4
    • Low G <10.5
    • No EPC

  • 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

  • How did you hear about Healthy Homes Dorset/referral Source

  • 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 Health Homes Dorset scheme, to help securement of grant funding available.

  • Customer Sign:

  • Completed By

  • Date:

Healthy Homes Dorset - Data Capture survey
Steve Bright

Healthy Homes Dorset - Data Capture survey

Data Capture Survey

Use this Template
The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.

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