Title Page
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Client
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Specify Client?
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Conducted on
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Prepared by
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Name of Competent Person
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Survey Type
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First Line of Address
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Front Elevation Photo
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Location
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Project
Health & Safety
Health & Safety Questions
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Is this the only energy efficiency measure for this property
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You must complete the following questions
Access Assessment
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Do you give consent for us to carry out works within your property?
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Reasoning?
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Resident Full Name and Signature
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Is there an overhead main power cable to the property that needs sheathing before scaffold erected?
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Are there any conservatories or out buildings that require a scaffold bridge for this job?
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Are there any restrictions to the property i.e. Low bridge, neighbours access required?
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Comments
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Does the property have a main pedestrian route or a public walkway directly on one of the elevations?
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Comments
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Is there adequate parking close to the property?
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Comments
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Any parking restrictions i.e. Residents parking?
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Comments
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Will the proposed works affect neighbouring properties?
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Comments
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Photographic evidence
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Has the neighbouring property been notified of the imminent works?
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Date of notification given-
Occupant Assessment
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Is the property in a suitable condition for the proposed works to be carried out?
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Comments
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Photographic evidence
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Is the property highlighted as flagged or at risk?
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Comments
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Do the occupants have any physical disabilities that pose any significant risks?
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Comments
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Do the occupants have any learning difficulties or mental health issues where our activities may pose any significant risks?
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Comments
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Are there any potential risks regarding minors in the property?
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Comments
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Are there any potential risks regarding pets in the property?
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Comments
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Is the resident aware of any presence of protected species (e.g., bats, birds, mice) or plants that could be subject to special protection?
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Comments
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Is the property high risk of biological waste or vermin? (Add photo if required)
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Comments
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Does the resident use hypodermic needles?
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Where is the sharps bin located/comments
Asbestos Assessment
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Are we in receipt of or have access to the asbestos survey or register for this property ?
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Asbestos Assessment Needs to be Checked
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Comments
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Has asbestos been identified ?
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Comments
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Photographic evidence
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Have the health and safety questions been completed on another survey
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You may proceed to the next page
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This health and safety section must be completed
Access Assessment
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Do you give consent for us to carry out works within your property?
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Reasoning?
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Resident Full Name and Signature
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Is there an overhead main power cable to the property that needs sheathing before scaffold erected?
-
Are there any conservatories or out buildings that require a scaffold bridge for this job?
-
Are there any restrictions to the property i.e. Low bridge, neighbours access required?
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Comments
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Does the property have a main pedestrian route or a public walkway directly on one of the elevations?
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Comments
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Is there adequate parking close to the property?
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Comments
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Any parking restrictions i.e. Residents parking?
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Comments
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Will the proposed works affect neighbouring properties?
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Comments
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Photographic evidence
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Has the neighbouring property been notified of the imminent works?
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Date of notification given-
Occupant Assessment
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Is the property in a suitable condition for the proposed works to be carried out?
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Comments
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Photographic evidence
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Is the property highlighted as flagged or at risk?
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Comments
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Do the occupants have any physical disabilities that pose any significant risks?
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Comments
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Do the occupants have any learning difficulties or mental health issues where our activities may pose any significant risks?
-
Comments
-
Are there any potential risks regarding minors in the property?
-
Comments
-
Are there any potential risks regarding pets in the property?
-
Comments
-
Is the resident aware of any presence of protected species (e.g., bats, birds, mice) or plants that could be subject to special protection?
-
Comments
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Is the property high risk of biological waste or vermin? (Add photo if required)
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Comments
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Does the resident use hypodermic needles?
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Where is the sharps bin located/comments
Asbestos Assessment
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Are we in receipt of or have access to the asbestos survey or register for this property ?
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Asbestos Assessment Needs to be Checked
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Comments
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Has asbestos been identified ?
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Comments
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Photographic evidence
Property
Property Elevations
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Which Elevations exist on this property
- Front
- Rear
- Left from front
- Right from front
- Extension
- Other elevations
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Specify
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Photo of Other Elevation
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Photo of Front Elevation
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Photo of Rear Elevation
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Photo of Left from Front Elevation
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Photo of Right from Front Elevation
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Photo of Extension Elevation(s)
External Inspection
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External existing issues e.g. blown bricks, missing mortar, damp, mould or vegetation growth
- No External Issues Visible
- Blown Bricks
- Missing Mortar
- Damp
- Mould
- Vegetation Growth
- Other
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Which Elevations Have Issues
- Front
- Rear
- Left from front
- Right from front
- Extension
- Other elevations
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Specify what issues are present
Roof
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Visual Condition of Roof Externally
Internal Condition
Walls
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Construction Type
- Cavity Wall
- Solid Brick
- System Built
- Metal Frame
- Other
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Visual Condition of Walls
Flooring
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Floor Construction Detail
- Solid Concrete
- Suspended Timber
- Suspended, Not Timber
- Ground Bearing Concrete
- Other
- Unknown
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Visual Condition of Floor
Internal Inspection
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Internal existing issues e.g. condensation, damp, mould or signs of leaks
- No Internal Issues Visible
- Damage to Ceiling
- Water Leak/Stain on Ceiling
- Low Level Damp Near Skirting Boards
- Black Mould in the Corners of the Rooms
- Black Mould on the Ceiling and Walls
- Condensation on the Windows and External Walls
- Other
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What Rooms?
- Lounge
- Kitchen
- Bedroom 1
- Bedroom 2
- Bedroom 3
- Bedroom 4
- Bathroom
- W/C
- Office
- Other
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Specify what issues are present
Other Areas
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Any Other Areas of the Property in Need of Maintenance that might affect the performance of the proposed EEM
Existing EEM's
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Any Existing Energy Efficiency Measures
- None
- Cavity Wall Insulation
- 300mm+ Loft Insulation
- External Wall Insulation
- Heating Upgraded
- Thermostat Upgraded
- Solar PV
- Other
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What Other Measures?
Heating System
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Main Heating type, plus take a photo of the appliance ID and rating plate.
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Photo of appliance name/make/model/rating plate.
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Location of the flue, please take a photo.
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Secondary Heat source
- No other heating present
- Electric Effect Fire
- Gas Fire with Flue
- Gas Fire Flush Fitted
- Open Fire
- Wood Burner
- Other
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Specify
Existing Windows & Doors
Existing Windows & Doors
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Existing Glazing Type
- Single
- Double (Pre 2001)
- Double (2002 +)
- Triple
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Is there any historic glass present
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What Rooms Have Windows or Doors
- Hallway
- Living Room
- Dining Room
- Kitchen
- Bathroom
- W/C
- Bedroom 1
- Bedroom 2
- Bedroom 3
- Bedroom 4
- Bedroom 5
- Office
- Other
Living Room
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Include General Room Photo's
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Photo's of All Windows & Doors in Room
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What Openings
- Door
- Window 1
- Window 2
- Window 3
- Patio/Sliding Door
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Size of Door
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Orientation of Door
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
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Size of Window 1
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Orientation of Window 1
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
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Size of Window 2
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Orientation of Window 2
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
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Size of Window 3
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Orientation of Window 3
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
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Size of Door
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Orientation of Door
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
Bathroom
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Include General Room Photo's
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Photo's of All Windows & Doors in Room
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What Openings
- Door
- Window 1
- Window 2
- Window 3
- Patio/Sliding Door
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Size of Door
-
Orientation of Door
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
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Size of Window 1
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Orientation of Window 1
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
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Size of Window 2
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Orientation of Window 2
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
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Size of Window 3
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Orientation of Window 3
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
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Size of Door
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Orientation of Door
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
Other
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Specify Room
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Include General Room Photo's
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Photo's of All Windows & Doors in Room
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What Openings
- Door
- Window 1
- Window 2
- Window 3
- Patio/Sliding Door
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Size of Door
-
Orientation of Door
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
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Size of Window 1
-
Orientation of Window 1
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
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Size of Window 2
-
Orientation of Window 2
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
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Size of Window 3
-
Orientation of Window 3
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
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Size of Door
-
Orientation of Door
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
Dining Room
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Include General Room Photo's
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Photo's of All Windows & Doors in Room
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What Openings
- Door
- Window 1
- Window 2
- Window 3
- Patio/Sliding Door
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Size of Door
-
Orientation of Door
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
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Size of Window 1
-
Orientation of Window 1
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
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Size of Window 2
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Orientation of Window 2
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
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Size of Window 3
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Orientation of Window 3
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
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Size of Door
-
Orientation of Door
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
Kitchen
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Include General Room Photo's
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Photo's of All Windows & Doors in Room
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What Openings
- Door
- Window 1
- Window 2
- Window 3
- Patio/Sliding Door
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Size of Door
-
Orientation of Door
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
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Size of Window 1
-
Orientation of Window 1
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
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Size of Window 2
-
Orientation of Window 2
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
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Size of Window 3
-
Orientation of Window 3
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Door
-
Orientation of Door
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
W/C
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Include General Room Photo's
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Photo's of All Windows & Doors in Room
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What Openings
- Door
- Window 1
- Window 2
- Window 3
- Patio/Sliding Door
-
Size of Door
-
Orientation of Door
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Window 1
-
Orientation of Window 1
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Window 2
-
Orientation of Window 2
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Window 3
-
Orientation of Window 3
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Door
-
Orientation of Door
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
Bedroom 1
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Include General Room Photo's
-
Photo's of All Windows & Doors in Room
-
What Openings
- Door
- Window 1
- Window 2
- Window 3
- Patio/Sliding Door
-
Size of Door
-
Orientation of Door
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Window 1
-
Orientation of Window 1
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Window 2
-
Orientation of Window 2
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Window 3
-
Orientation of Window 3
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Door
-
Orientation of Door
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
Bedroom 2
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Include General Room Photo's
-
Photo's of All Windows & Doors in Room
-
What Openings
- Door
- Window 1
- Window 2
- Window 3
- Patio/Sliding Door
-
Size of Door
-
Orientation of Door
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Window 1
-
Orientation of Window 1
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Window 2
-
Orientation of Window 2
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Window 3
-
Orientation of Window 3
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Door
-
Orientation of Door
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
Bedroom 3
-
Include General Room Photo's
-
Photo's of All Windows & Doors in Room
-
What Openings
- Door
- Window 1
- Window 2
- Window 3
- Patio/Sliding Door
-
Size of Door
-
Orientation of Door
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Window 1
-
Orientation of Window 1
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Window 2
-
Orientation of Window 2
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Window 3
-
Orientation of Window 3
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Door
-
Orientation of Door
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
Bedroom 4
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Include General Room Photo's
-
Photo's of All Windows & Doors in Room
-
What Openings
- Door
- Window 1
- Window 2
- Window 3
- Patio/Sliding Door
-
Size of Door
-
Orientation of Door
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Window 1
-
Orientation of Window 1
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Window 2
-
Orientation of Window 2
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Window 3
-
Orientation of Window 3
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Door
-
Orientation of Door
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
Bedroom 5
-
Include General Room Photo's
-
Photo's of All Windows & Doors in Room
-
What Openings
- Door
- Window 1
- Window 2
- Window 3
- Patio/Sliding Door
-
Size of Door
-
Orientation of Door
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Window 1
-
Orientation of Window 1
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Window 2
-
Orientation of Window 2
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Window 3
-
Orientation of Window 3
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Door
-
Orientation of Door
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
Office
-
Include General Room Photo's
-
Photo's of All Windows & Doors in Room
-
What Openings
- Door
- Window 1
- Window 2
- Window 3
- Patio/Sliding Door
-
Size of Door
-
Orientation of Door
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Window 1
-
Orientation of Window 1
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Window 2
-
Orientation of Window 2
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Window 3
-
Orientation of Window 3
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Door
-
Orientation of Door
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
Hallway
-
Include General Room Photo's
-
Photo's of All Windows & Doors in Room
-
What Openings
- Door
- Window 1
- Window 2
- Window 3
- Patio/Sliding Door
-
Size of Door
-
Orientation of Door
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Window 1
-
Orientation of Window 1
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Window 2
-
Orientation of Window 2
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Window 3
-
Orientation of Window 3
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
-
Size of Door
-
Orientation of Door
- North
- North-East
- East
- South-East
- South
- South-West
- West
- North-West
- To Internal Hall
- N/A
Ventilation PIBI
-
A ventilation PIBI must be submitted with the Windows and Doors PIBI.
-
Has a ventilation PIBI been conducted
-
A ventilation PIBI must be completed
-
Ventilation PIBI will be provided to show:
-
Wet room mechanical ventilation is working or will be replaced
-
All rooms have or will have passive vents/trickle vents
-
All habitable rooms have or will have the required door undercuts
Points Considered
-
Use of a Step ladder/ladder
-
Access and Egress
-
Manual Handing
-
Hand Tools/Power Tools
-
Vibration
-
Noise
-
Dust
-
House Keeping
-
Lone Working
EEM Specific Survey Information
EEM Information
-
Have relevant checks been undertaken to determine if asbestos containing materials are present
-
Is the nature and extent of the survey known to the customer and is it in line with their expectations
-
Are the arrangements made for site access and installation materials storage adequate and appropriate for the installation to be undertaken
-
The installation work will not result in non-compliance with the building regulations in relation to:
-
Workmanship
-
Materials
-
Structural Stability
-
Fire Safety
-
Resistance to Moisture
-
Any avoidable thermal bridging
-
Any unsafe operation of combustion appliances
-
Compromise the functionality of existing ventilation ducts/systems
-
Compromise the functionality and/or safety of existing services (gas, electric, water, telephone, etc.)
-
Any requirements stated by the supplier
Resident Sign Off
Resident Sign Off
-
Has the Customer been made aware of the level of disruption and is happy for the works to go ahead?
-
Resident to sign
Sign Off
Assessment Sign off
-
Surveyor/Competent Person Signature and Full Name