Mr Mrs Miss Other
First Name
Surname
Address

Postcode
Tel incl code
email address
When was your home built?

Property Type:(check all those that apply)
Detached
Semi Detached
End Terrace
Mid Terrace
With Passage

Do you own your home rent your home

if renting, is it:
Privately
from council
from housing association
Tied or other

if flat/maisonette is it:
Tower Block (6 or more storeys)
Custom Block (5 or less storeys)
Above a shop or office
Divided house

Is there a roof above your flat? Yes No

if Yes is it: Sloping Flat Part Both

Does your home have a loft? Yes No

If yes, is the loft a heated room in regular use? Yes No

How many floors are there(excluding lofts/cellars) 1 2 3 4 5

How many bedrooms do you have 1 2 3 4 5

How many living/dining/playrooms/studies? 1 2 3 4 5

Is your building Listed In a conservation area

Does the loft have flooring? Yes No

What type of walls do you have? Solid Brick Solid Concrete Solid Stone Cavity (insulated) Cavity (uninsulated) Mixed Timber frame Don't know

What type of windows do you have? All Double/Secondary Glazed Most Double/Secondary Glazed Some Double/Secondary Glazed All Single Glazed Some Single Glazed

Are the windows/ external doors draught proofed? None Some Most All

Is your main heating: Boiler/radiators Separate heaters/fires Warm air system Electric storage heaters Other

What is your main heating fuel? Gas Electricity Oil Solid Fuel Bottled Gas LPG (Bulk)

Do you have a separate fire that you use regularly? Electric Gas Solid Fuel No

Does your heating have: Storage heater dials Programmer/timer
Room thermostat Thermostatic radiator valves None

If you have a boiler, how old is it? Less than 5 years old 5 - 10 years old 11 - 15 years old More than 15 years

If you have radiators, do they have foil behind them? None Some All

is your boiler a condensing boiler? Yes No Don't Know

How is your hot water provided?
Gas/oil/coal range
from heating system
Instant:Gas/combi boiler
Electric
Electric Immersion
On Peak
Off Peak
Dual electric immersion
Back Boiler

If you have a hot water storage tank, is the insulation: No tank No Insulation Solid foam Jacket With gaps No gaps

Are the pipes from the boiler to the tank insulated? Yes No Don't Know

Do you have hot water controls? Yes No
On/off switch Programmer Thermostat

Do you have any low energy lights? Yes No    How many? One Some Most All

is your cooker: Gas/oil/coal range Gas Electric Gas hob/Electric Oven

Do you have:
Fridge
Fridge/Freezer
Freezer
Dishwasher
Washing Machine
Tumble dryer

Is a member of your household? Over 60 In receipt of benefits

How many people live in your home? 1 2 3 4 5 6 7

How many are under 18 years old? 1 2 3 4 5

If you do not wish us to send your further information about energy efficiency in the future and forward your details to organisations associated with us please tick

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