Household Support Fund (Energy) Reporting Form

• Date & Time of Visit

  Date

• Reference Number

• Customers Full Name (including Title)

• Location
  Address

• First Line of Address

• Telephone Number (home)

• Telephone Number (Mobile)

• Email Address

• Completed By

  Chris Denman

  Johnny Fox

  Steve Bright

  Peter Bywater

  Mandy Ledwith

Begin the visit by sitting down with the resident for a discussion about how they use energy in their home. We are looking to gather information about whether they are generally warm enough and if they have any issues with cold and damp.

• Have you been show evidence confirming eligibility

  Yes

  No

  N/A

• Tenure

  Owner Occupier

  Private Rental

  Social Housing

• Please provide details of Landlord

• Do you generally feel warm enough in your property

  Yes

  No

  N/A

• What do you feel prevents you from feeling warm enough in your home?

  Select Heating is Sufficiently to Expensive Heating System is inadequate Poor Building Fabric Draughts Feel cold due to a health condition Other

  • Heating is Sufficiently to Expensive
  • Heating System is inadequate
  • Poor Building Fabric
  • Draughts
  • Feel cold due to a health condition
  • Other

• Do you have problems with Condensation, Mould or Damp

  Yes

  No

  N/A

• Number Of Adults in the Property

• Adults Date of Birth

• Number of Children in the Property?

• Children's Date of Birth

• Benefits or Allowances

  Yes

  No

  N/A

• Please give details of Benefits or Allowances

• Annual Household Income?

• What is the main way you heat your home

  Select Condensing Combination Boiler Condensing System Boiler with Cylinder Non-Condensing Combination Boiler Non-Condensing System Boiler with Cylinder & Elec Immersion Fire with Back Boiler Storage Heaters Room Heaters Open Fires Wood Stove Warm Air System Communal Heating System Air Source Heat Pump None

  • Condensing Combination Boiler
  • Condensing System Boiler with Cylinder
  • Non-Condensing Combination Boiler
  • Non-Condensing System Boiler with Cylinder & Elec Immersion
  • Fire with Back Boiler
  • Storage Heaters
  • Room Heaters
  • Open Fires
  • Wood Stove
  • Warm Air System
  • Communal Heating System
  • Air Source Heat Pump
  • None

• Are these High Heat Retention ESH

  Yes

  No

  N/A

• Are these mains Gas or Electric

  Mains Gas

  Electric

• What fuel does this system use

  Select Coal Electric - Off Peak Electric - On Peak Oil LPG Mains Gas Wood

  • Coal
  • Electric - Off Peak
  • Electric - On Peak
  • Oil
  • LPG
  • Mains Gas
  • Wood

• How do you heat the hot water in your home

  Same boiler as Main Heating

  Separate Boiler

  Electric on Demand Heater

  Immersion Heater/Tank

BOILER

• How old is the Boiler

• Is the Boiler Broken

  Yes

  No

  N/A

• Is this a "NO HEAT" situation (gas only)

  Yes

  No

  N/A

• Tick if the boiler is broken and there is No Heating / No Hot Water / Leak / Repair Identified. Answer all the questions on boiler make, fault, and add some note on any other information that might help. eg, Info on any issues, Vulnerability, Location. PLEASE DO NOT MAKE ANY PROMISES.

• Please include information regarding this situation

• Boiler Make & Model

• How is the Boiler Mounted

  Floor Mounted

  Wall Mounted

  Back Boiler

• Where is the Boiler located in the Property

  Select Garage/Out-House/Shed Outside Ground Floor First Floor Loft Cellar/Basement Other

  • Garage/Out-House/Shed
  • Outside
  • Ground Floor
  • First Floor
  • Loft
  • Cellar/Basement
  • Other

• Please specify location

• How many Radiators in the Property

• What are the known faults? (these issues may be resolved by following manufacturers guidance)

  Select Boiler warning indicators are illuminated Boiler Ignition or Pilot intermittent or failing Boiler Continually losing pressure Hot water is not working or reaching temperature Boiler Cuts out during operation Boiler is making excessive noise during operation Boiler is visibly leaking water Boiler casing cracked, Corroded or otherwise breached Boiler controls physically damaged & cannot be operated Boiler is already condemned or has warning notice

  • Boiler warning indicators are illuminated
  • Boiler Ignition or Pilot intermittent or failing
  • Boiler Continually losing pressure
  • Hot water is not working or reaching temperature
  • Boiler Cuts out during operation
  • Boiler is making excessive noise during operation
  • Boiler is visibly leaking water
  • Boiler casing cracked, Corroded or otherwise breached
  • Boiler controls physically damaged & cannot be operated
  • Boiler is already condemned or has warning notice

• Please provide CLEAR photos of Boiler, Make & Model, Location, Flue, Any Issues

  Media

HEATING CONTROLS

• How do you control the times & temperatures of your heating

  Select Programmer/Timer Room Thermostat TRV's Smart Controls/Thermostat None

  • Programmer/Timer
  • Room Thermostat
  • TRV's
  • Smart Controls/Thermostat
  • None

• Guidance on heating controls given

  Yes

  No

  N/A

• Do you think the resident understood the heating control guidance

  Yes

  No

  N/A

• If No, Why?

ELECTRIC STORAGE HEATERS

• How many "Old Style" storage heaters are present

• How many "New Style" storage heaters are present

• Are the storage heaters broken

  Yes

  No

  N/A

• How Many are broken

• Make and Model of storage heaters

• Dwelling Type

  House

  Flat

  Bungalow

  Maisonette

  Park Home

• Detachment

  Select Detached Semi-Detached Mid-Terrace End-Terrace Single Park Home Double Park Home

  • Detached
  • Semi-Detached
  • Mid-Terrace
  • End-Terrace
  • Single Park Home
  • Double Park Home

• Flat/Maisonette Location

  Ground Floor

  Mid Floor

  Top Floor

• For Flat or Maisonette, Please list number of Outside Walls

  Two or Fewer

  Three or More

• Detachment

  Select Detached Semi-Detached Mid-Terrace End-Terrace Single Park Home Double Park Home

  • Detached
  • Semi-Detached
  • Mid-Terrace
  • End-Terrace
  • Single Park Home
  • Double Park Home

• Flat/Maisonette Location

  Ground Floor

  Mid Floor

  Top Floor

• For Flat or Maisonette, Please list number of Outside Walls

  Two or Fewer

  Three or More

• Detachment

  Select Detached Semi-Detached Mid-Terrace End-Terrace Single Park Home Double Park Home

  • Detached
  • Semi-Detached
  • Mid-Terrace
  • End-Terrace
  • Single Park Home
  • Double Park Home

• Number of Bedrooms in Dwelling

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

WALLS

• Dwelling Wall Type?

  Cavity Wall

  Solid Wall

  System Build

  Timber Framed

• Have the Walls been retrofitted with Cavity wall Insulation?

  Yes

  No

  N/A

• Photo Of Evidence

  Media

• Can the Installer park a large CWI Install Vehicle close enough to the property to Complete the Install of CWI, (Parking to be no more than 50m from the closest point of the Property)?

  Yes

  No

  N/A

• Please Confirm there are No Visible Drill marks on all Elevations of the Property

  Confirmed

  Not Confirmed

• Please Confirm that you have measured the External Wall width to be grater than 260mm (Door or Window revel)

  Confirmed

  Not Confirmed

• Wall Width is (mm)

• Are there any defects that will be made worse by installing CWI? (eg, Cracks, Brick Erosion, Repointing Needed, Penetrating or Rising Damp, Damp Proof course less that 100mm from ground level.)

  Yes

  No

  N/A

• Please List Defects

  Select Cracks in Wall Brick Erosion Repointing Needed Penetrating Or Rising Damp Low Damp roof Course

  • Cracks in Wall
  • Brick Erosion
  • Repointing Needed
  • Penetrating Or Rising Damp
  • Low Damp roof Course

• Are there any reasons why you may feel some walls may not be installed?

  Yes

  No

  N/A

• Reasons For this are,?

  Select Rendering Garage/Extension Attached Conservatory Wall isTile Hung in areas Restricted Access Other

  • Rendering
  • Garage/Extension Attached
  • Conservatory
  • Wall isTile Hung in areas
  • Restricted Access
  • Other

• Photo of all Elevations

  Media

• Photo of Brick Patten /Render

  Media

• Photo of Wall Width

  Media

• Photo of any restrictions (extensions, conservatory, access)

  Media

• Photo of Damp Proof Course

  Media

LOFT

• Is the loft Space easily accessible

  Yes

  No

  N/A

• reason for restriction

• Is there a loft ladder?

  Yes

  No

  N/A

• Is the loft space reasonable clear of belongings?

  Yes

  No

  N/A

• Will the resident be able to empty loft if required?

  Yes

  No

  N/A

• What is the current depth of the loft insulation?

  150mm and Below

  150mm and Above

• What is current Depth (mm)

  Select 170mm 200mm 225mm 250mm 275mm 300mm Other

  • 170mm
  • 200mm
  • 225mm
  • 250mm
  • 275mm
  • 300mm
  • Other

• Please List Depth

• As above 150mm there may not be funding. Would resident like a Private Quote for Loft top up

  Yes

  No

  N/A

• Please pass back to Ridgewater to arrange Survey

• Depth of loft Insulation

  Select 0mm 25mm 50mm 75mm 100mm 125mm 150mm

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

• Are there Water tanks & Pipe work in the loft to be insulated?

  Yes

  No

  N/A

• Are there any Down lights that will be affected by the insulation?

  Yes

  No

  N/A

• How Many?

• Is there any damage to any of the ceilings (cracks, water damage)?

  Yes

  No

  N/A

• Please list rooms with damage

• Photo of Loft Access

  Media

• Photo of overall Loft Area (each corner of loft)

  Media

• Photo of Loft Depth with tape measure

  Media

• Photo of Water tanks & Pipe work

  Media

• Do you struggle to pay your energy bills?

  Yes

  No

  N/A

• What sort of Energy Contract do you have?

  Dual Fuel

  Separate Contracts

  Electric Only

• If Separate Contracts please add notes to each question in relation to Gas/Electric

• Who is you Current Energy Supplier?

• What Kind of Energy tariff are you on?

  Variable Rate

  Fixed Rate

• If Fixed, Do you know how much longer remains on your fixed tariff deal?

  Less than Three Months

  More than Three Months

  Don't Know

• Is there an Early Termination penalty on your fuel contract?

  Select Variable Rate - With Penalty Variable Rate- Without Penalty Fixed Rate - With Penalty Fixed Rate -Without Penalty

  • Variable Rate - With Penalty
  • Variable Rate- Without Penalty
  • Fixed Rate - With Penalty
  • Fixed Rate -Without Penalty

• How do you pay for your energy?

  Select Monthly Bill Quarterly Bill Direct debit Pre-Payment

  • Monthly Bill
  • Quarterly Bill
  • Direct debit
  • Pre-Payment

• Does the resident receive the Warm Home Discount?

  Yes

  No

  N/A

• Did you help the resident register for their Energy Company's PSR?

  Yes

  No doesn't want to

  Already Registered

  Not Relevant

• Did you help the resident register for their Water Company's Social tariff?

  Yes

  No doesn't want to

  Already Registered

  Not Relevant

SWITCHING, If the resident could benefit from switching Energy Provider. Go through the switching process with them provided they are willing. Ensure that the resident understands the you will only be helping them to search for a better deal for their energy and that it is totally up to them if they decide to switch. If the resident receives the WHD, it is important to ensure that switching will not result in them losing out. You must either switch them to another supplier that provides the WHD, or ensure that their annual savings are at least £150.

• Will the resident switch to a new tariff or supplier for there Gas?

  Select Yes, New supplier Yes, New tariff with same supplier No, Doesn't want to No, Not the residents decision No, Will do later No, Better deal available No gas at the Property

  • Yes, New supplier
  • Yes, New tariff with same supplier
  • No, Doesn't want to
  • No, Not the residents decision
  • No, Will do later
  • No, Better deal available
  • No gas at the Property

• Will the resident switch to a new tariff or supplier for there Electric

  Select Yes, New supplier Yes, New tariff with same supplier No, Doesn't want to No, Not the residents decision No, Will do later No, Better deal available No gas at the Property

  • Yes, New supplier
  • Yes, New tariff with same supplier
  • No, Doesn't want to
  • No, Not the residents decision
  • No, Will do later
  • No, Better deal available
  • No gas at the Property

INCOME SUPPORT

• Do you feel that you're getting all the state benefits that you are entitled to?

  Yes

  No

  Not Sure

• Are there any other household bills, that are a challenge to pay or to understand?

  Yes

  No

  N/A

• Do you mind if I ask. Have you built up much debt with any of those people? Are people pursuing you for Money?

  Yes

  No

  Would not Discuss

The resident could benefit from a referral to CAB that provides Income, Debt & Budgeting advice. If you are going to refer then to CAB then you now need to read out this consent statement:

• I would like to refer you to Citizens Advice that delivers income advice by telephone. They will contact you and help you make sure that you are getting all the benefits you are entitled to and give you lots of useful advice. In order to access this service, we need to share your name and contact details with Citizens Advice. Do you consent to being referred and your contact information being passed across to Citizens Advice.

  Select Yes, Consent given for my details to be passed to CAB No, I do not give consent for my details to be passed to CAB

  • Yes, Consent given for my details to be passed to CAB
  • No, I do not give consent for my details to be passed to CAB

• What is the best contact details to provide Citizens Advice with?

• Any Notes that may help Citizens Advice get in touch

Look around the property to identify any elevated fire risks or potential category 1 hazards that could be referred on. Fire risks will be referred to the Local Fire Service for a Safe & Well visit. Serious Hazards will be reported (with the tenants consent) to their council or Landlord.

FIRE RISK ASSESSMENT

• Are there Smoke alarms present?

  Select Yes Yes, but not enough/poorly located Yes, but battery flat/Not working No

  • Yes
  • Yes, but not enough/poorly located
  • Yes, but battery flat/Not working
  • No

• Is there a carbon Monoxide alarm installed?

  Yes

  No

  N/A

• Fire Risk Issues?

  Select Occupants over 65 Child occupants under 10 Resident is a Smoker that smokes indoors Resident with mobiliity issues Resident with signs of Cognitive impairment Evidence of any fires or burns in the property

  • Occupants over 65
  • Child occupants under 10
  • Resident is a Smoker that smokes indoors
  • Resident with mobiliity issues
  • Resident with signs of Cognitive impairment
  • Evidence of any fires or burns in the property

If you are going to refer for a Fire Service Safe & Well Visit, you must read this out:

• I think you would benefit from a visit from the Fire Service Safe & Well Team. if they agree, they will arrange a date and time to come out and see you. They can give you advice on Fire Safety, and fix smoke alarms. In order to arrange this, we will need to share your Name & contact details with the fire service, and the information I've gathered on why you think you are entitled to a home visit. I can mark this for a referral now. You need to agree to this and consent to us sharing this information about you and your home with the Fire Service.

  Select Yes, Consent is given for my details to be passed to the Fire Service. No, I do not give Consent for my details to be passed to the Fire Service.

  • Yes, Consent is given for my details to be passed to the Fire Service.
  • No, I do not give Consent for my details to be passed to the Fire Service.

HAZARD RISK ASSESSMENT

• Are there any obvious hazards in the home?

  Yes

  No

  N/A

• Risk of falling os stairs/steps

  Select Significantly lower risk than average Average risk Significantly higher risk than average Extreme risk N/a

  • Significantly lower risk than average
  • Average risk
  • Significantly higher risk than average
  • Extreme risk
  • N/a

• Risk of falling on level surface

  Select Significantly lower risk than average Average risk Significantly higher risk than average Extreme risk N/a

  • Significantly lower risk than average
  • Average risk
  • Significantly higher risk than average
  • Extreme risk
  • N/a

• Risk of falling between levels

  Select Significantly lower risk than average Average risk Significantly higher risk than average Extreme risk N/a

  • Significantly lower risk than average
  • Average risk
  • Significantly higher risk than average
  • Extreme risk
  • N/a

• Risk of Damp & Mould growth

  Select Significantly lower risk than average Average risk Significantly higher risk than average Extreme risk N/a

  • Significantly lower risk than average
  • Average risk
  • Significantly higher risk than average
  • Extreme risk
  • N/a

• Risk of Food Saftey

  Select Significantly lower risk than average Average risk Significantly higher risk than average Extreme risk N/a

  • Significantly lower risk than average
  • Average risk
  • Significantly higher risk than average
  • Extreme risk
  • N/a

• Risk of Personal Hygiene (bathroom & WC)

  Select Significantly lower risk than average Average risk Significantly higher risk than average Extreme risk N/a

  • Significantly lower risk than average
  • Average risk
  • Significantly higher risk than average
  • Extreme risk
  • N/a

• Risk of dangerous cold

  Select Significantly lower risk than average Average risk Significantly higher risk than average Extreme risk N/a

  • Significantly lower risk than average
  • Average risk
  • Significantly higher risk than average
  • Extreme risk
  • N/a

• Please provide more information on Hazards recorded

• If a Private/Social Tenant, Have you reported the Hazard(s) to your Landlord?

  Select Not Relevant, Home Owner No, Haven't got around to it No, I'm to worried about the consequences Yes. ones or twice, not sure if anything will happen Yes, my Landlord has tried to sort it out, but still a problem Yes.many times, but nothing ever happens Not a Landlord issue

  • Not Relevant, Home Owner
  • No, Haven't got around to it
  • No, I'm to worried about the consequences
  • Yes. ones or twice, not sure if anything will happen
  • Yes, my Landlord has tried to sort it out, but still a problem
  • Yes.many times, but nothing ever happens
  • Not a Landlord issue

If you are going to refer a hazard, you must read this out

• If we refer this hazard into the council, and they think it is serious enough, they will arrange an inspection by one of their environmental health team. If it is a private rented property, they may take enforcement action on your landlord to sort the problem. I can mark this for referral to the council now. You need to agree to this and consent to us sharing this information about you and your home with the council.

  Select Yes, I consent for this information to be passed to the council No, I do not consent for this information to be passed to the council

  • Yes, I consent for this information to be passed to the council
  • No, I do not consent for this information to be passed to the council

SAFEGUARDING ASSESSMENT

• Have you identified a serious safeguarding issue?

  Yes

  No

  N/A

• Please provide more information regarding safeguarding issue

• Please provide note that will help with the referral, and then Email notes and visit details to peter@ridgewaterenergy.co.uk

• Will the resident wash clothes at 30 degrees?

  Yes

  No

  All ready does this

• Will the resident turn off lights if not needed?

  Yes

  No

  All ready does this

• Will the resident try to reduce the number of clothes they was each week?

  Yes

  No

  All ready does this

• Will the resident try to reduce showering time by one minute?

  Yes

  No

  All ready does this

• Will the resident wash up in a bowl rather than a flowing tap?

  Yes

  No

  All ready does this

• Will the resident only boil as much water as needed and stop the kettle from boiling for too long?

  Yes

  No

  All ready does this

• Will the resident dry clothes outside during the summer months?

  Yes

  No

  All ready does this

• Will the resident avoid using standby mode on appliances?

  Yes

  No

  All ready does this

• Will the resident replace one bath a week with a shower?

  Yes

  No

  All ready does this

• Will the Resident turn the Thermostat down by 1 degree?

  Yes

  No

  All ready does this

• Will the resident consider doing Batch cooking?

  Yes

  No

  All ready does this

• Does the resident cook using a Microwave, Slow Cooker, or Air fryer?

  Yes

  No

  All ready does this

• Does the resident keep their freezer full?

  Yes

  No

  All ready does this

• Does the resident wear extra layers when it's cold?

  Yes

  No

  All ready does this

• Does the resident make sure they have hot drinks & meals when it's cold?

  Yes

  No

  All ready does this

• Does the resident make sure they heat at least one room?

  Yes

  No

  All ready does this

• Does the resident use residual heat in the oven to finish cooking food?

  Yes

  No

  All ready does this

Now run through with the householder the various onward referrals that are appropriate. Make sure you have their consent for us to pass on their details to the organisations concerned.

ECO or HHD REFERRAL (Have a look back at your Heating & insulation surveys to see which ECO/HHD measures you think can be referred). If the resident isn't a DWP HHcro match, They may still be eligible under the councils ECOflex scheme or HHD

• What is the ECO/HHD Referral status?

  Select Occupant wants to be referred for an ECO/HHD funded measure Occupant not currently eligible Social Housing property so can not be referred No viable ECO/HHD measure identified at this address Occupant not interested in any ECO/HHD referrals

  • Occupant wants to be referred for an ECO/HHD funded measure
  • Occupant not currently eligible
  • Social Housing property so can not be referred
  • No viable ECO/HHD measure identified at this address
  • Occupant not interested in any ECO/HHD referrals

IF THE TENURE IS OWNER OCCUPIER, (Explain that the funding available for ECO measures come from the ECO energy efficiency scheme or HHD. Funding amounts vary depending on the size of the property and how energy efficient the property already is and it doesn't always cover the cost. Some councils will pay funding shortfalls, and we will find out from them. Sometimes the home owner will need to make a contribution to the cost.)

• If there is a Funding Shortfall, are you able to make a contribution to the cost?

  Yes

  No

  N/A

IF THE TENURE IS PRIVATE RENTAL, (Explain that we will need the Landlords permission to carry out works on the property and may need an agreement to pay a contribution to the cost. We will contact the Landlord to seek consent. Now collect the Landlords details.)

• Landlords Full Name (including title)

• Landlords Postal Address & Post Code

• Landlords Contact Phone Number

• Landlords Email Address

MEASURES TO BE REFERRED

• Which ECO measures are you referring?

  Select Cavity Wall Insulation Loft Insulation Room-in-roof Boiler replacement FTCH Storage Heater Replacement N/A

  • Cavity Wall Insulation
  • Loft Insulation
  • Room-in-roof
  • Boiler replacement
  • FTCH
  • Storage Heater Replacement
  • N/A

• Which HHD Measures are you referring?

  Select Cavity Wall Insulation Loft Insulation N/A

  • Cavity Wall Insulation
  • Loft Insulation
  • N/A

OWNER OCCUPIER CONSENT STATEMENT

• I agree to be referred for one or more ECO/HHD measures. I understand and accept that the information gathered in this visit about my home and circumstances and the photos taken will be used by Ridgewater Energy to access whether I am eligible for funding and whether my home is suitable for the measure.

  Select Yes, I give my consent for the Information to be used No, I do not give my consent for the information to be used N/A

  • Yes, I give my consent for the Information to be used
  • No, I do not give my consent for the information to be used
  • N/A

PRIVATE TENANT CONSENT STATEMENT

• I agree to be referred for one or more ECO/HHD measures. I understand and accept that the information gathered in this visit about my home and circumstances and the photos taken will be used by Ridgewater Energy to access whether I am eligible for funding and whether my home is suitable for the measure. You will also contact my Landlord for permission for any work or Contributions required.

  Select Yes, I give my consent for the Information to be used No, I do not give my consent for the information to be used N/A

  • Yes, I give my consent for the Information to be used
  • No, I do not give my consent for the information to be used
  • N/A

COMPLETION SIGNATURE

• Tenant/Homeowner Signature

  Sign

• Assessors Signature

  Sign

• Date of visit

  Date

• Please List Appliances to Be installed

  Select Under Counter Fridge -No Icebox - (W54 x H84 x D60cm) Under Counter Fridge - With Icebox - (W54 x H84 x D60cm) Family Fridge Freezer - (W55 x H174 x D54cm) Washing Machine 7kg - (W60 x H85 xD52cm) Electric Cooker - (W50 x H90 x D60cm) Electric Cooker - (W60 x H90 x D60cm) Microwave (only if Broken or None) - max size (W54 x H30 x D40cm) Gas Cooker - (W60 X H90 X D60) Gas Cooker - (W50 X H90 X D60)

  • Under Counter Fridge -No Icebox - (W54 x H84 x D60cm)
  • Under Counter Fridge - With Icebox - (W54 x H84 x D60cm)
  • Family Fridge Freezer - (W55 x H174 x D54cm)
  • Washing Machine 7kg - (W60 x H85 xD52cm)
  • Electric Cooker - (W50 x H90 x D60cm)
  • Electric Cooker - (W60 x H90 x D60cm)
  • Microwave (only if Broken or None) - max size (W54 x H30 x D40cm)
  • Gas Cooker - (W60 X H90 X D60)
  • Gas Cooker - (W50 X H90 X D60)

• Does the beneficiary have any communication issues

  Yes

  No

  N/A

• Please detail any communication issues

• Does anyone else need to be contacted to make arrangements?

  Yes

  No

  N/A

• Alternative Contact Name

• Relationship to applicant

• Alternative Contact Phone Number

Accessibility Questions

• Is there a place to park for the delivery crew which is within sight of the property?

  Yes

  No

  N/A

• If parking permit is required, is the resident able to make one available for the crew?

  Yes

  No

  Not Required

• If a Flat/Maisonette, Which floor is the property on?

• is there a lift in the building?

  Yes

  No

  N/A

• Is there a socket near the appliance (if cooker, an Isolation switch & hardwired plug socket)?

  Yes

  No

  N/A

• If ordering a washing machine, will the crew have access to turn the water on/off, and do the pipes have access to the plumbing under the sink?

  Yes

  No

  N/A

• For Cookers, the Hot Zone is the area behind & above the hob (65cm above for Electric cookers, and 5cm each side). Can you confirm there is no wallpaper or any combustible material on the hot zone.

  Yes

  No

  N/A

• Please add any other information about accessibility or the property.

ELIGIBLITY INFORMATION

• The tenant confirms that they are responsible for/own the appliance(s) being replaced/installed

  Yes

  No

  N/A

• Is there an existing appliance to be removed? (under BCP we can supply first time appliance)

  Yes

  No

  N/A

• The beneficiary understands that the existing appliance(s) (at least 8 years old) will be removed & disposed of when the new appliance is being installed (tick box to confirm)

• Does the resident have any Health Needs? (eg, needs fridge to store medication or carers need Washing Machine to wash clothes/bedding)?

  Yes

  No

  N/A

• General Note – please put anything else here you want to record about the visit

• Are there any Draughts or other easy measures lacking?

  Yes

  No

  N/A

• Customer consents to installation of Easy Measures

  Yes

  No

  N/A

LIST NUMBER OF EASY MEASURES INSTALLED

• 8.5w B22 Bayonet warm white bulb

• 9w E27 Large Screw warm white bulb

• 5.5w E14 Small Screw Candle warm white bulb

• 5.5w C37 Bayonet Candle warm white bulb

• GU10 Downlight Bulb

• Number of Radiators on outside walls

• Number of Radiator panels used

• Remote Controls Sockets

• Hot Water Tank Jacket

• Number of External Doors draught proofed

• Number of 2m Retro Draught Proof Strip (White) used?

• Number of 2m Retro Draught Proof Strip (Brown) used

• 914mm Bottom Door Brush (White)

• 914mm Bottom Door Brush (Brown)

• Letterbox Brush (White)

• Letterbox Brush (Brown)

• Shower Save Water regulator

• Shower Timer