Submit your pre-survey information

Please complete the form to the best of your knowledge. We will use this information to plan your survey, and as part of our data collection to demonstrate the the impact of C.H.E.E.S.E surveys. Note that you can't edit the information once you have submitted it, but you can resubmit the information by submitting this form again. Fields marked with a * are required.

Your details

Your name*

Address line*

Post code*

Do you have any special requirements that we need to be aware of during the survey?

Do you have any illnesses or disabilities?
Will you be able to accompany the surveyor around your home for two to three hours during the survey?
Do you have any pets that will be present in your home during the survey?

Details of your home

Building type

(tick for yes) Can you heat your home to a comfortable temperature in the winter?

Year of construction

Wall construction

Occupation type

Primary heating type

Secondary heating type

Water heating type

Cooking type

Depth of loft insulation (mm)

Number of open fireplaces

Amount of double glazing (%)

Number of occupants

(tick for yes) Are you aware of any asbestos, exposed or not exposed, in the building?

If yes, please give details

Gas use

Annual consumption (kWh

(tick for yes) Is the value based on estimated use?

Start date (dd/mm/yyyy)

End date (dd/mm/yyyy)

Electricity use

Annual consumption (kWh

(tick for yes) Is the value based on estimated use?

Start date (dd/mm/yyyy)

End date (dd/mm/yyyy)

Other energy use

Annual spend on solid fuels (£)

Annual contribution from renewable generation (kWh)

Please make sure you have read our privacy notice that explains what personal data we collect, why we collect it and how we keep it safe.