Title Page

  • Date & Time of Visit

  • Reference Number

  • Customers Full Name (including Title)

  • Location
  • First Line of Address

  • Telephone Number (home)

  • Telephone Number (Mobile)

  • Email Address

  • Completed By

Home Visit Form Page 1

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

  • Tenure

  • Please provide details of Landlord

  • Do you generally feel warm enough in your property

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

  • Do you have problems with Condensation, Mould or Damp

  • Number Of Adults in the Property

  • Adults Date of Birth

  • Number of Children in the Property?

  • Children's Date of Birth

  • Benefits or Allowances

  • Please give details of Benefits or Allowances

  • Annual Household Income?

Home Visit Form Page 2 (Heating)

  • What is the main way you heat your home

  • Are these High Heat Retention ESH

  • Are these mains Gas or Electric

  • What fuel does this system use

  • How do you heat the hot water in your home

BOILER

  • How old is the Boiler

  • Is the Boiler Broken

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

  • 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

  • Where is the Boiler located in the Property

  • Please specify location

  • How many Radiators in the Property

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

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

HEATING CONTROLS

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

  • Guidance on heating controls given

  • Do you think the resident understood the heating control guidance

  • 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

  • How Many are broken

  • Make and Model of storage heaters

Home Visit Form Page 3 (Insulation)

  • Dwelling Type

  • Detachment

  • Flat/Maisonette Location

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

  • Detachment

  • Flat/Maisonette Location

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

  • Detachment

  • Number of Bedrooms in Dwelling

WALLS

  • Dwelling Wall Type?

  • Have the Walls been retrofitted with Cavity wall Insulation?

  • Photo Of Evidence

  • 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)?

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

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

  • 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.)

  • Please List Defects

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

  • Reasons For this are,?

  • Photo of all Elevations

  • Photo of Brick Patten /Render

  • Photo of Wall Width

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

  • Photo of Damp Proof Course

LOFT

  • Is the loft Space easily accessible

  • reason for restriction

  • Is there a loft ladder?

  • Is the loft space reasonable clear of belongings?

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

  • What is the current depth of the loft insulation?

  • What is current Depth (mm)

  • Please List Depth

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

  • Please pass back to Ridgewater to arrange Survey

  • Depth of loft Insulation

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

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

  • How Many?

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

  • Please list rooms with damage

  • Photo of Loft Access

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

  • Photo of Loft Depth with tape measure

  • Photo of Water tanks & Pipe work

Home Visit Form Page 4 (Energy Bills & Income Maximisation)

  • Do you struggle to pay your energy bills?

  • What sort of Energy Contract do you have?

  • 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?

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

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

  • How do you pay for your energy?

  • Does the resident receive the Warm Home Discount?

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

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

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?

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

INCOME SUPPORT

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

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

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

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.

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

  • Any Notes that may help Citizens Advice get in touch

Home Visit Form Page 5 (Fire Service & Hazard referrals)

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?

  • Is there a carbon Monoxide alarm installed?

  • Fire Risk Issues?

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.

HAZARD RISK ASSESSMENT

  • Are there any obvious hazards in the home?

  • Risk of falling os stairs/steps

  • Risk of falling on level surface

  • Risk of falling between levels

  • Risk of Damp & Mould growth

  • Risk of Food Saftey

  • Risk of Personal Hygiene (bathroom & WC)

  • Risk of dangerous cold

  • Please provide more information on Hazards recorded

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

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.

SAFEGUARDING ASSESSMENT

  • Have you identified a serious safeguarding issue?

  • 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

Home Visit Form Page 6 (Energy Efficiency Advice)

  • Will the resident wash clothes at 30 degrees?

  • Will the resident turn off lights if not needed?

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

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

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

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

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

  • Will the resident avoid using standby mode on appliances?

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

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

  • Will the resident consider doing Batch cooking?

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

  • Does the resident keep their freezer full?

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

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

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

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

Home Visit Form Page 7 (Wrap-up & Summery of Onward referrals)

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?

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?

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?

  • Which HHD Measures are you referring?

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.

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.

COMPLETION SIGNATURE

  • Tenant/Homeowner Signature

  • Assessors Signature

  • Date of visit

Home Visit Form Page 8 (Appliances)

  • Family Size Fridge Freezer

  • Select Size (cm)

  • Fridge With/Without Icebox (54/55cm W x 84/85cm H x 59/60/62cm D)

  • Choose size. Width, Height, Depth

  • With or With Out Ice Box

  • Under Counter Freezers (54/55cm W x 84/85cm H x 60/62cm D)

  • Choose size. Width, Height, Depth

  • Electric Cooker (50/60cm W x 90cm H x 60cm D)

  • Choose width 50cm or 60cm

  • Gas Cooker (60cm W x 90cm H x 60cm D)

  • 7KG Washing Machine (60cm W x 85cm H x 54cm D)

  • 8KG Washing Machine (60cm W x 85cm H x 52/54/60cm D)

  • Select type and size

  • Black Microwave (44/54cm W x 25/30cm H x 35/40cm D)

  • Choose Size

  • Does the beneficiary have any communication issues

  • Please detail any communication issues

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

  • Alternative Contact Name

  • Relationship to applicant

  • Alternative Contact Phone Number

Accessibility Questions

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

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

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

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

  • is there a lift in the building?

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

  • 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?

  • 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.

  • 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

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

  • 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)?

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

Home Visit Form Page 9 (Easy Measures)

  • Are there any Draughts or other easy measures lacking?

  • Customer consents to installation of Easy Measures

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

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.