ECO Form (Internal)

Property Ownership Status

Social Housing Homeowner Private Rented

Rural (Check Ofgem Site)

Yes No

Does anyone in your household receive a state benefit? Select all that apply.

No Benefits Universal Credit Income Based Job Seekers Allowance Income Related Employment and Support Allowance Income Support Housing Benefit

Route 2 (Must select 2 of the following. 1&3 and proxies 6&7 cannot be used in combination with each other)

1.Homes in England in Lower-layer Super Output Area (LSOA)1-3 on the English Indices of Deprivation 2019 or homes in Wales in LSOA 1-3 on the Welsh Index of Multiple Deprivation 20199 , or homes in Scotland in “data zone” 1-3 on the Scottish Index of Multiple Deprivation 2020 2.A person living at the premises receives a Council Tax reduction on the grounds of low income. 3.A person living at the premises is considered to be vulnerable to the cold under the National Institute for Health and Care Excellence (NICE) Guidance: Recommendation 2, for a reason other than their low income. 4.A child living at the premises is eligible for free school meals, due to low-income 5.A person living at the premises is supported by a LA run scheme that is named and described in their Statement of Intent, and established to support people living on a low income and vulnerable to the cold under NICE Guideline NG6, 6.A person living at the premises has been referred to the LA for support by their energy supplier, Citizens Advice or Citizen’s Advice Scotland because they have been identified by the referrer as struggling to pay their gas or electricity bills 7.The household has been Identified through supplier debt data to Identify either Non Pre-payment meter households ( non-PPM), or Pre-payment meter households(PPM)

People with cardiovascular conditions

Yes No

People with respiratory conditions (in particular, chronic obstructive pulmonary disease and childhood asthma)

Yes No

People with cardiovascular conditions

Yes No

People with mental health conditions

Yes No

People with disabilities

Yes No

Older people (65 and older)

Yes No

Households with young children (from new born to school age)

Yes No

Pregnant women

(Evidence: require signed letter from Doctor / GP indicating the householder is vulnerable to living in a cold home due to one of the above circumstances)

Yes No

Do any of the householders receive free school meals due to low income?

Yes No

What is your main heating type?

Mains Gas Oil LPG Electric Boiler Storage Heaters Electric Room Heater Multifuel Other

Is your boiler condensing or non condensing? Does it have a white plastic pipe coming from below the boiler?

Condensing - Yes white plastic pipe Non-Condensing - No white plastic pipe Don't know Not Applicable

Underfloor Heating

Yes No

Heating Controls

None Thermostat Programmer TRVs Zonal

Hot Water Tank

Yes No

Insulation

Foam Jacket

What is the current EPC band for the property? Check post code and address on the Scottish EPC register

E F G No EPC

What is the total floor area of the property? Check EPC data

0-72 73-97 98-199 200+ No EPC

Is this job progressing further?

Yes No

How did you hear about us?

Flyer Recommendation Internet search engine (eg. Google) TV Radio Social media (eg. Facebook) Referral Reward Shelter Scotland Other

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