NELEEAC Home Energy Check Form

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Working to promote Energy Efficiency in Buildings

See how much money you could save with this FREE Home Energy Check! (UK Residents only)

Energy Efficiency is an Energy Saving Trust initiative backed by the Government

Every home is different, so by letting us know as much as possible about where you live, we can tell you how much you could be saving. Simply fill out this questionnaire and we'll send you a personalised report with recommendations for your home, their cost and details of the savings you could make. We will also include details of any grants which you may be able to claim.

If you have any questions, or would simply like more information, please call free on 0800 512012

Customer Details
Title: Mr Mrs Ms Miss Other
First name:
Surname:
Address:

Town:
County:
Postcode:
What year was your home built?
Property type
Do you own or rent your home?

Insulation Details

How much loft insulation do you have?

Does your loft have any flooring? (this may obstruct adding extra insulation)

Yes No (or no loft)

What type of outside walls do you have?
Solid brick walls can usually be identified by the brick pattern (see below)


Cavity brick wall	Solid brick wall

Do you have double glazed windows or secondary glazing?

How many of your external doors and windows are draughtproofed?
(assume sealed double-glazed units to be draught-proofed)

Heating and Hot Water
What is your main heating system?
What fuel does it use?
Do you have a separate fire that you use regularly?
What type of heating controls do you have on the main system?
How old is this main heating system?
Do you have foil behind radiators?
Do you have a condensing boiler?	No Yes
How is your hot water usually provided?
Which hot water tank insulation applies to you?
If you have a hot water tank, is there insulation on the pipework between the tank and the boiler?
What hot water controls do you have? Please tick all that apply	No controls On/off switch Timer/Programmer Hot water tank thermostat

Lights and Appliances
Do you have any low energy light bulbs?
What type of cooker do you have?
Which of the following household appliances do you have and how old are they?
	no	yes 0-5 yrs	yes 6-10 yrs	yes 11+ yrs	yes age unknown
Fridge/Freezer
Fridge
Freezer
Washing Machine
Dishwasher
Tumble Dryer

Household Details
Is a member of your household over 60?	Yes No
Is a member of your household in receipt of benefits?	Yes No (This information is only used to see if you may qualify for a grant)
How many people live in your home?
How many of the people in your home are under 16 years old?
Where did you find out about this Web site?

The Energy Saving Trust, the data controller, is collecting your data for the purpose of supplying you with energy efficiency advice that will help you reduce your energy use. The Trust will also retain your data for the purposes of carrying out research and statistical analysis into the energy efficiency of UK housing stock. Your local Energy Conservation Authority will also receive your data for the purposes of energy efficiency monitoring, targeting and reporting. In future, the Trust may wish to send you further relevant information on energy efficiency and sustainable energy use.
If you do not wish to receive information from us please tick here:

We may also disclose your details, if relevant, to other organisations that may wish to provide you with further relevant information on improving the Energy Efficiency of your home. If you do not wish to have your details forwarded to these organisations please tick here:

Please make sure you have entered your full name and address then click the submit button to send the form.

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