Title Page

  • Client

  • Specify Client?

  • Conducted on

  • Prepared by

  • Name of Competent Person

  • Survey Type

  • First Line of Address

  • Front Elevation Photo

  • Location
  • Project

Health & Safety

Health & Safety Questions

  • Is this the only energy efficiency measure for this property

  • You must complete the following questions

Access Assessment

  • Do you give consent for us to carry out works within your property?

  • Reasoning?

  • Resident Full Name and Signature

  • 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?

  • Comments

  • Does the property have a main pedestrian route or a public walkway directly on one of the elevations?

  • Comments

  • Is there adequate parking close to the property?

  • Comments

  • Any parking restrictions i.e. Residents parking?

  • Comments

  • Will the proposed works affect neighbouring properties?

  • Comments

  • Photographic evidence

  • Has the neighbouring property been notified of the imminent works?

  • Date of notification given-

Occupant Assessment

  • Is the property in a suitable condition for the proposed works to be carried out?

  • Comments

  • Photographic evidence

  • Is the property highlighted as flagged or at risk?

  • Comments

  • Do the occupants have any physical disabilities that pose any significant risks?

  • Comments

  • 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

  • Is the property high risk of biological waste or vermin? (Add photo if required)

  • Comments

  • Does the resident use hypodermic needles?

  • Where is the sharps bin located/comments

Asbestos Assessment

  • Are we in receipt of or have access to the asbestos survey or register for this property ?

  • Asbestos Assessment Needs to be Checked

  • Comments

  • Has asbestos been identified ?

  • Comments

  • Photographic evidence

  • Have the health and safety questions been completed on another survey

  • You may proceed to the next page

  • This health and safety section must be completed

Access Assessment

  • Do you give consent for us to carry out works within your property?

  • Reasoning?

  • Resident Full Name and Signature

  • 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?

  • Comments

  • Does the property have a main pedestrian route or a public walkway directly on one of the elevations?

  • Comments

  • Is there adequate parking close to the property?

  • Comments

  • Any parking restrictions i.e. Residents parking?

  • Comments

  • Will the proposed works affect neighbouring properties?

  • Comments

  • Photographic evidence

  • Has the neighbouring property been notified of the imminent works?

  • Date of notification given-

Occupant Assessment

  • Is the property in a suitable condition for the proposed works to be carried out?

  • Comments

  • Photographic evidence

  • Is the property highlighted as flagged or at risk?

  • Comments

  • Do the occupants have any physical disabilities that pose any significant risks?

  • Comments

  • 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

  • Is the property high risk of biological waste or vermin? (Add photo if required)

  • Comments

  • Does the resident use hypodermic needles?

  • Where is the sharps bin located/comments

Asbestos Assessment

  • Are we in receipt of or have access to the asbestos survey or register for this property ?

  • Asbestos Assessment Needs to be Checked

  • Comments

  • Has asbestos been identified ?

  • Comments

  • Photographic evidence

Property

Property Elevations

  • Which Elevations exist on this property

  • Specify

  • Photo of Other Elevation

  • Photo of Front Elevation

  • Photo of Rear Elevation

  • Photo of Left from Front Elevation

  • Photo of Right from Front Elevation

  • Photo of Extension Elevation(s)

External Inspection

  • External existing issues e.g. blown bricks, missing mortar, damp, mould or vegetation growth

  • Which Elevations Have Issues

  • Specify what issues are present

Roof

  • Visual Condition of Roof Externally

Internal Condition

Walls

  • Construction Type

  • Visual Condition of Walls

Flooring

  • Floor Construction Detail

  • Visual Condition of Floor

Internal Inspection

  • Internal existing issues e.g. condensation, damp, mould or signs of leaks

  • What Rooms?

  • Specify what issues are present

Other Areas

  • Any Other Areas of the Property in Need of Maintenance that might affect the performance of the proposed EEM

Existing EEM's

  • Any Existing Energy Efficiency Measures

  • What Other Measures?

Heating System

  • Main Heating type, plus take a photo of the appliance ID and rating plate.

  • Photo of appliance name/make/model/rating plate.

  • Location of the flue, please take a photo.

  • Secondary Heat source

  • Specify

Existing Windows & Doors

Existing Windows & Doors

  • Existing Glazing Type

  • Is there any historic glass present

  • What Rooms Have Windows or Doors

Living Room

  • Include General Room Photo's

  • Photo's of All Windows & Doors in Room

  • What Openings

  • Size of Door

  • Orientation of Door

  • Size of Window 1

  • Orientation of Window 1

  • Size of Window 2

  • Orientation of Window 2

  • Size of Window 3

  • Orientation of Window 3

  • Size of Door

  • Orientation of Door

Bathroom

  • Include General Room Photo's

  • Photo's of All Windows & Doors in Room

  • What Openings

  • Size of Door

  • Orientation of Door

  • Size of Window 1

  • Orientation of Window 1

  • Size of Window 2

  • Orientation of Window 2

  • Size of Window 3

  • Orientation of Window 3

  • Size of Door

  • Orientation of Door

Other

  • Specify Room

  • Include General Room Photo's

  • Photo's of All Windows & Doors in Room

  • What Openings

  • Size of Door

  • Orientation of Door

  • Size of Window 1

  • Orientation of Window 1

  • Size of Window 2

  • Orientation of Window 2

  • Size of Window 3

  • Orientation of Window 3

  • Size of Door

  • Orientation of Door

Dining Room

  • Include General Room Photo's

  • Photo's of All Windows & Doors in Room

  • What Openings

  • Size of Door

  • Orientation of Door

  • Size of Window 1

  • Orientation of Window 1

  • Size of Window 2

  • Orientation of Window 2

  • Size of Window 3

  • Orientation of Window 3

  • Size of Door

  • Orientation of Door

Kitchen

  • Include General Room Photo's

  • Photo's of All Windows & Doors in Room

  • What Openings

  • Size of Door

  • Orientation of Door

  • Size of Window 1

  • Orientation of Window 1

  • Size of Window 2

  • Orientation of Window 2

  • Size of Window 3

  • Orientation of Window 3

  • Size of Door

  • Orientation of Door

W/C

  • Include General Room Photo's

  • Photo's of All Windows & Doors in Room

  • What Openings

  • Size of Door

  • Orientation of Door

  • Size of Window 1

  • Orientation of Window 1

  • Size of Window 2

  • Orientation of Window 2

  • Size of Window 3

  • Orientation of Window 3

  • Size of Door

  • Orientation of Door

Bedroom 1

  • Include General Room Photo's

  • Photo's of All Windows & Doors in Room

  • What Openings

  • Size of Door

  • Orientation of Door

  • Size of Window 1

  • Orientation of Window 1

  • Size of Window 2

  • Orientation of Window 2

  • Size of Window 3

  • Orientation of Window 3

  • Size of Door

  • Orientation of Door

Bedroom 2

  • Include General Room Photo's

  • Photo's of All Windows & Doors in Room

  • What Openings

  • Size of Door

  • Orientation of Door

  • Size of Window 1

  • Orientation of Window 1

  • Size of Window 2

  • Orientation of Window 2

  • Size of Window 3

  • Orientation of Window 3

  • Size of Door

  • Orientation of Door

Bedroom 3

  • Include General Room Photo's

  • Photo's of All Windows & Doors in Room

  • What Openings

  • Size of Door

  • Orientation of Door

  • Size of Window 1

  • Orientation of Window 1

  • Size of Window 2

  • Orientation of Window 2

  • Size of Window 3

  • Orientation of Window 3

  • Size of Door

  • Orientation of Door

Bedroom 4

  • Include General Room Photo's

  • Photo's of All Windows & Doors in Room

  • What Openings

  • Size of Door

  • Orientation of Door

  • Size of Window 1

  • Orientation of Window 1

  • Size of Window 2

  • Orientation of Window 2

  • Size of Window 3

  • Orientation of Window 3

  • Size of Door

  • Orientation of Door

Bedroom 5

  • Include General Room Photo's

  • Photo's of All Windows & Doors in Room

  • What Openings

  • Size of Door

  • Orientation of Door

  • Size of Window 1

  • Orientation of Window 1

  • Size of Window 2

  • Orientation of Window 2

  • Size of Window 3

  • Orientation of Window 3

  • Size of Door

  • Orientation of Door

Office

  • Include General Room Photo's

  • Photo's of All Windows & Doors in Room

  • What Openings

  • Size of Door

  • Orientation of Door

  • Size of Window 1

  • Orientation of Window 1

  • Size of Window 2

  • Orientation of Window 2

  • Size of Window 3

  • Orientation of Window 3

  • Size of Door

  • Orientation of Door

Hallway

  • Include General Room Photo's

  • Photo's of All Windows & Doors in Room

  • What Openings

  • Size of Door

  • Orientation of Door

  • Size of Window 1

  • Orientation of Window 1

  • Size of Window 2

  • Orientation of Window 2

  • Size of Window 3

  • Orientation of Window 3

  • Size of Door

  • Orientation of Door

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

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.