HUG2 Data Capture Form.

• Title

  Select Mr. Mrs. Ms. Miss. Dr. Reverend.

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

• Assessment Date

  Date

• Customer Full Name

• HUG Scheme Ref No:

• Customer Address
  Address

• First Line of Address

• Mobile Telephone No:

• Home Telephone No:

• Alternative Telephone No:

• Email Address

• Best Number to Contact & Time of Day.

  Select Home - AM Home - PM Mobile - AM Mobile - PM Alternative - AM Alternative - PM Email

  • Home - AM
  • Home - PM
  • Mobile - AM
  • Mobile - PM
  • Alternative - AM
  • Alternative - PM
  • Email

• Property Tenure

  Owner Occupier

  Private Rental

• Leasehold or Freehold

  Leasehold

  Freehold

• Landlord Name

• Landlord Address

• Landlord contact Details (phone or email)

• Date Of Birth

  Date

• Benefits

  Yes

  No

  N/A

• Please List

  Select Income based jobseekers Allowance (JSA) Income related Employment & Support Allowance (ESA) Income Support (IS) Pension Credit Guarantee Credit (PCGC) Working Tax Credit (WTC) Child Tax Credit (CTC) Universal Credit (UC) Housing Benefit (HB) Pension Credit Savings Credit (PCSC) Child Benefit (subject to income caps & composition) Attendance Allowance (AA) Disability Living Allowance (DLA) Armed Forces Independence Payment Carer's Allowance (CA) Industrial Injuries Disablement Benefit (IIDB) Personal Independence Payment (PIP) Severe Disablement Allowance (SDA) Mobility Supplement (MS)

  • Income based jobseekers Allowance (JSA)
  • Income related Employment & Support Allowance (ESA)
  • Income Support (IS)
  • Pension Credit Guarantee Credit (PCGC)
  • Working Tax Credit (WTC)
  • Child Tax Credit (CTC)
  • Universal Credit (UC)
  • Housing Benefit (HB)
  • Pension Credit Savings Credit (PCSC)
  • Child Benefit (subject to income caps & composition)
  • Attendance Allowance (AA)
  • Disability Living Allowance (DLA)
  • Armed Forces Independence Payment
  • Carer's Allowance (CA)
  • Industrial Injuries Disablement Benefit (IIDB)
  • Personal Independence Payment (PIP)
  • Severe Disablement Allowance (SDA)
  • Mobility Supplement (MS)

• Health Conditions

  Yes

  No

  N/A

• Please List

• Household Income

  Above £31,000 p/y

  Below £31,000 p/y

• Please ask for proof of Income, and record yearly amount.

• Has the LA Flex form been completed with this resident

  Yes

  No

  N/A

• Reason for not completing

• Please collect all Evidence required for Flex

• No of Adults in Property

• No of Children in Property

• Current EPC Band (if one)

  Select A B C D E F G No EPC on Property

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

• New EPC band & Score

• Is the property in a Low Super Output Area (LSOA) - "check HUG website if needed" http://www.dorset-hug.co.uk/

  Yes

  No

  N/A

• Please add the LSOA post code

• Property Type

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

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

• No of Bedrooms

• Main Building Age

• No of Floors/Storeys

• No of External Walls

• No of Rooms

• How many are habitable rooms.

• Does the property have an Extension

  Yes

  No

  N/A

• Extension Age

• Constrution of Extension

  Cavity

  Solid Wall

  Timber Framed

  System Build

• Roof Type of Extension

  Pitched

  Hipped

  Flat

  Mansard

• Smart Meter Installed

  Yes

  No

  N/A

• Heating System Type

  Select ESH HHR_ESH On_peak ERH LPG Boiler Oil Boiler Solid Fuel Boiler (wood/coal) Biomass Electric Central heating System

  • ESH
  • HHR_ESH
  • On_peak ERH
  • LPG Boiler
  • Oil Boiler
  • Solid Fuel Boiler (wood/coal)
  • Biomass
  • Electric Central heating System

• Fuel Type

  Electric

  LPG

  Oil

  Solid Fuel

• Heating Controls in Situ

  Select No time or thermostat control of room temperature Programmer and room thermostat Programmer, room thermostat and TRVs Programmer, TRVs and bypass Programmer, no room thermostat TRVs and bypass Programmer, TRVs and boiler energy manager Programmer and at least two room thermostats room thermostat only Manual charge control Automatic Charge Control Appliance control only Smart Heating Controls Radbots

  • No time or thermostat control of room temperature
  • Programmer and room thermostat
  • Programmer, room thermostat and TRVs
  • Programmer, TRVs and bypass
  • Programmer, no room thermostat
  • TRVs and bypass
  • Programmer, TRVs and boiler energy manager
  • Programmer and at least two room thermostats
  • room thermostat only
  • Manual charge control
  • Automatic Charge Control
  • Appliance control only
  • Smart Heating Controls
  • Radbots

• Heating Controls Required

  Select Programmer Thermostat TRVs Smart controls Radbots

  • Programmer
  • Thermostat
  • TRVs
  • Smart controls
  • Radbots

• Current Annual Electricity Use per year (kwh/£)

• Loft Insulation Less or Equal to 200mm

  Yes

  No

  N/A

• Can the loft be accessed easily

  Yes

  No

  N/A

• Photo of overall loft area (each corner)

  Media

• Please record true loft depth (mm)

• Photo of loft depth

  Media

• Are all ceilings in a good state of repair

  Yes

  No

  N/A

• Please identify the areas in question and provide pictures.

• Cavity Wall Insulation required to Main building or Extension

  Yes

  No

  N/A

• Main Building or Extension to be insulated

  Main Building Only

  Extension Only

  Main Building & Extension

• Photo of each elevation

  Media

• Building Condition

  Good

  Fair

  Poor

• Is DPC visible above 150mm above ground. (if no DPC is visible, add notes & Photos as to why)

  Yes

  No

  Unsure

• Please Borescope Walls and add photos

  Media

• Does the property have Vents

  Yes

  No

  N/A

• Which Vents are present

  Select Under Floor Vents Window Trickle Vents Room Vents Extractor Fan Combustion Vent

  • Under Floor Vents
  • Window Trickle Vents
  • Room Vents
  • Extractor Fan
  • Combustion Vent

• Are there any Access Issues - if yes please evidence

  Yes

  No

  N/A

• Does the property have any Party Walls

  Yes

  No

  N/A

• Can the construction of the Party Wall be identified from the loft space

  Yes

  No

  N/A

• Construction type

  Cavity Construction

  Solid Construction

  Timber Framed / System Build

• Can party wall insulation be installed if neighbouring property agrees.

  Yes

  No

  N/A

• Client Interested in Park home Insulation

  Yes

  No

  N/A

• Is Park Home Double or Single unit

  Double Park Home

  Single Park Home

• Photo of each Elevation of the Park Home

  Media

• Will all elements of the Park Home require insulation

  Select Walls Floor Roof

  • Walls
  • Floor
  • Roof

• What is the condition of the walls

  Good

  Fair

  Poor

• What is the condition of the external Ply Skin

  Good

  Fair

  Poor

• is there any existing wall Insulation

  Yes

  No

  Unsure

• Remedial Works required on external walls prior to instal

  Yes

  No

  Unsure

• Is there access to the Floor

  Yes

  No

  N/A

• is there existing insulation.

  Yes

  No

  N/A

• Please select the Floor joints present

  Supporting jacks & base

  Supporting tie downs & base

  None

• Is there access to the roof

  Yes

  No

  N/A

• is there any existing insulation

  Yes

  No

  N/A

• Are there any metal rafters

  Yes

  No

  N/A

• what is the Roof verge overhang (mm)

• Client Interested in Solar PV

  Yes

  No

  N/A

• Client comfortable using mobile wireless app to monitor panel output

  Yes

  No

  N/A

• Roof Type

  Pitched

  Hipped

  Flat

  Mansard

• Height of Roof from Ground

• Pitch of Roof Orientation

  Select North East South West North-East South-East North-West South-West

  • North
  • East
  • South
  • West
  • North-East
  • South-East
  • North-West
  • South-West

• Pitch of Roof (Elevation in Degree º)

  Horizontal

  30º

  45º

  60º

  Vertical

• Roof Material

  Tile

  Slate

  Felt

• Dorma Windows Present

  Yes

  No

  N/A

• Any Over-Shading

  Yes

  No

  N/A

• Any Access Issues. (scaffolding/parking)

  Yes

  No

  N/A

• Photo of all Roof Elevations

  Media

• Photo of Tile Type (close up)

  Media

• Photo of Current Electrical System/Board

  Media

• Photo of Potential Space in Loft for Invertor

  Media

• Photo Inside Loft to show (roof struts/purlins/joists/rafters)

  Media

• Any other useful photos

  Media

• Client interested in Air Source Heat Pump

  Yes

  No

  N/A

• Do they have the space for the outside HP unit? (Typical dimensions W 1000mm x H 1000mm x D 600mm.includes clearance required in front of unit.)

  Yes

  No

  N/A

• Can the HP Unit be housed 1 meter away from any boundaries or neighbouring properties

  Yes

  No

  N/A

• Do they have space for the hot water tank? (Typical dimensions W 1000mm x H 2000mm x D 700mm)

  Yes

  No

  N/A

• Photo of possible Location

  Media

• Do they have space for the Internal heat exchanger, where required? (W 500mm x H 800mm x D 350mm)

  Yes

  No

  N/A

• Is there space below it to ground level for the pressure vessel & pipework? (although often these are in a loft space so less of an issue (On Smaller heat demand systems could use a "Monoblock" system that have all the heat exchanger parts in the outside unit.

  Compliant

  Non-Compliant

• Do they have radiators at present and if so, are they on standard pipework?

  Yes

  No

  N/A

• Photo of Radiators

  Media

• Micro-boro pipe work not possible under scheme

  Compliant

  Non-Compliant

• Would the resident require extra help in setting heating controls after install?

  Yes

  No

  N/A

• HHR Storage Heaters required

  Yes

  No

  N/A

• Does the Property have a Ecom-7 Supply

  Yes

  No

  N/A

• Photo of Electric Meter

  Media

• Can meter be changed

  Yes

  No

  N/A

• Number of Pre-existing Heaters

• Number of HHR ESH to be installed into the property

• Will the new HHR ESH heat 100% of the Property

  Yes

  No

  Unsure

Solid Wall Insulation

• Solid Wall Insulation

  Yes

  No

  N/A

• Photo of Each Elevation

  Media

• Building Condition

  Good

  Fair

  Poor

• is it a system build fabric

  Yes

  No

  Unsure

• Photo of DPC

  Media

• Does the Property have any Vents

  Yes

  No

  N/A

• Which vents are present

  Select Under Floor Vents Window Trickle Vents Room Vents Extractor Fan Combustion Vent

  • Under Floor Vents
  • Window Trickle Vents
  • Room Vents
  • Extractor Fan
  • Combustion Vent

• access Issues

  Yes

  No

  N/A

Room In Roof Insulation

• Does Property have qualifying RIR

  Yes

  No

  N/A

• Number of rooms in RIR area

• Is there access to Residual Areas

  Yes

  No

  Unsure

• Which areas require Insulating

  Select Pitched Roof/Loft Flat Dormer Roofer Dormer Walls Sloping Ceilings Stud/Dwarf Walls Gable/Party Walls

  • Pitched Roof/Loft
  • Flat Dormer Roofer
  • Dormer Walls
  • Sloping Ceilings
  • Stud/Dwarf Walls
  • Gable/Party Walls

Flat Roof Insulation

• Flat Roof

  Yes

  No

  N/A

• Flat Roof m2

• Flat roof Insulated

  Yes

  No

  Unsure

• Photo of Flat Roof (from above & ground level)

  Media

Solar Thermal

• Client Interested in Solar Thermal

  Yes

  No

  N/A

• Client comfortable using mobile wireless app to monitor panel output

  Yes

  No

  N/A

• Roof Type

  Pitched

  Hipped

  Flat

  Mansard

• Height of Roof from Ground

• Pitch of Roof Orientation

  Select North East South West North-East South-East North-West South-West

  • North
  • East
  • South
  • West
  • North-East
  • South-East
  • North-West
  • South-West

• Roof Material

  Tile

  Slate

  Felt

• Dorma Windows Present

  Yes

  No

  N/A

• Any Over-Shading

  Yes

  No

  N/A

• Any Access Issues. (scaffolding/parking)

  Yes

  No

  N/A

• Photo of all Roof Elevations

  Media

• Photo of Tile Type (close up)

  Media

• Photo Inside Loft to show (roof struts/purlins/joists/rafters)

  Media

• Any other useful photos

  Media

Under Floor Insulation

• Under Floor Insulation required

  Yes

  No

  N/A

• Is there Access to the Under Floor

  Yes

  No

  Unsure

• Is there a minimum depth of 1 meter below the floor

  Yes

  No

  Unsure

• Is there adequate cross flow ventilation below the floor

  Yes

  No

  Unsure

• Can Access be made easily

  Yes

  No

  N/A

• Is there a minimum of 1 meter access below the floor

  Yes

  No

  Unsure

• Is there adequate cross flow ventilation below the floor

  Yes

  No

  Unsure

Low Energy Lighting

• LED light Bulbs Required

  Yes

  No

  N/A

• How Bulbs to be fitted & Fitting Required

Hot Water Tank Insulation

• Hot Water Tank present

  Yes

  No

  N/A

• Dose that Hot Water Tank require new insulation jacket

  Yes

  No

  N/A

Draught Proofing

• Draught Proofing Required

  Yes

  No

  N/A

• Number of Doors to be Draught Proofed

• Number of Windows to be Draught Proofed

• Dorset HUG2 Client Certification Form Complete

  Yes

  No

  N/A

• Evidence on Eligibility Checked

  Yes

  No

  N/A

• HUG2 leave behind notice given to client

  Yes

  No

  N/A

• CUSTOMER SIGNATURE - (PLEASE READ) - I can confirm that I have given consent for my qualifying evidence to be viewed by the assessor at the time of there visit, I have received relevant Data Protection & GDPR documents. and all other procedures that are required following there visit have been explained to me regarding further visits and installations.

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• Survey Completed By

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