ECO Surv Resident Retrofit Engagement & Survey Booking Form
Your details
Tenant / Resident name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Email address (if you use email)
example@example.com
Preferred method of contact:
Your preferred contact method
Phone Call
Text Message (SMS)
Email
Letter
Through family member or carer
Other
Best days to contact you
Please Select
Monday
Tuesday
Wednesday
Thursday
Friday
Any day
Before any improvements are planned, we need to carry out a home energy and condition survey.
When would you prefer us to visit? (Please give as many options as possible)
Morning or Afternoon?
Morning
Afternoon
Either
Are there any days or times we should avoid?
Do you have any pets we should be aware of?
Yes
No
Are there any access issues? (e.g. door entry system, mobility issues, parking limits)
Your Home & Comfort
Do you currently experience any of the following? (tick any)
Home feels cold in the winter
Home gets too hot in the summer
Draughts
Condensation on windows
Damp or mould
High energy bills
Rooms that are hard to heat
Ventilation issues (stuffy air, smells linger)
Other
Measures You Are Interested In
Not all homes are suitable for all measures, but we want to understand what matters to you.Which improvements would you like to know more about? (tick any)
Loft insulation
Wall insulation
Floor insulation
New windows or doors
Draught proofing
Heating systems improvements
Hot water systems improvements
Solar panels
Ventilation improvements
I am not sure / I would like advice
Please give any concerns about work happening in your home?
Communication & Support Needs
We want to make sure our service works for everyone.
Do you have any communication needs or disabilities we should be aware of? (Tick any that apply)
Hearing impairment
Visual impairment
Mobility difficulties
Learning disability
Neurodivergent condition
Mental health condition
Long-term illness
Language support
Other
Do you need information in a different format? (Tick any that apply)
Large print
Easy read
Braille
Different Language
Support person present during visits
Other
Having Your Say
Your views are important in deciding what improvements are designed for your home.
Is there anything you would like us to consider when planning work?
Do you have any previous experiences (good or bad) with home improvement works that you want us to know about?
Safeguarding and Wellbeing
Our staff are trained to recognise and report safeguarding concerns. If we see something that makes us worried about someone’s safety or wellbeing, we may need to share this with the appropriate professionals to help keep people safe.
Is there anything you would like us to know about your household that may affect how we carry out visits safely and respectfully?
Consent to Be Contacted About Retrofit Works
I confirm that I am happy for ECOSurv and its project partners to contact me about surveys and retrofit works & understand I can change my communication preferences at any time
Signature
Date
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Month
-
Day
Year
Date
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