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Where are the Zones?

Your questions about Warm Zones

Warmth in the home

Online self-assessment for
residents of Northumberland

If you are completing this online form for someone who doesn't live with you,
please remember to enter their details.

At any time you can clear all the selected values and start again by pressing this button:

SECTION 1 - PERSONAL DETAILS

Title: Mr Mrs Ms Miss Other (please specify)

Forename:

Surname:

Address
House:

Street:

Town/Area:

Postcode:

We must have a surname, house name/number and postcode - we cannot process the form otherwise!

Contact telephone number (including code):

(This number will be used if we need to arrange to visit to check if the household qualifies for a free grant)

Email address:

(This will provide us with another means to make contact regarding a possible appointment)

Date of birth: day month(1-12) year

Are you: the householder the householder's partner other (please specify)

SECTION 2 - BASIC PROPERTY DETAILS

1. When was your property built?

Pre 1900		1966 - 1975
1900 - 1918		1976
1919 - 1929		1977 - 1980
1930 - 1944		1981
1945 - 1949		1982 - 1990
1950 - 1964		1991 - 1995
1965		1996 or later
Don't know

2. What type of property do you live in?

Detached		Mid terrace (with passage)
Semi-detached		Top floor flat
End of terrace		Middle floor flat
Mid terrace		Bottom floor flat

3. Do you rent or own your property?

Own/Buying on mortgage		Renting privately
Renting from Council		Tied house/other
Renting from HousingAssociation

If you don't live in a flat, please go on to question 6.

4. If you live in a flat, what type of building is it in?

A tower block (6 or more storeys)
A custom block (up to 5 storeys)
Above a shop or office
Part of a divided house

5. Is there a roof above your flat?

Yes, sloping (pitched)
Yes, flat
Yes, part sloping (pitched) and part flat
Only part of the flat has a roof
No

6. How many floors does your home/flat have?

7. How many living or dining rooms do you have?

8. How many bedrooms do you have?

SECTION 3 - INSULATION

9. What type of outside walls do you have?


Cavity Wall	Solid Wall

Solid brick		Cavity - uninsulated
Solid concrete		Mixed
Solid stone		Modern Timber Frame
Cavity - insulated		Don't Know

10. Does your home have a loft? Yes No

11. If Yes, how much loft insulation do you have?

None		100 mm (4 inches)
25 mm (1 inch)		150 mm (6 inches)
50 mm (2 inches)		200 mm (8 inches)
75 mm (3 inches)		Don't know

12. Does your loft have a floor? Yes No

13. What type of glazing do you have?

All single glazed
Some double/secondary glazing
Mostly double/secondary glazing
All double/secondary glazing

14. What are the majority of your window frames made from?

Wood Metal PVCu

15. Are your windows and doors draughtproofed?

None Some Most All

16. Is your hot water cylinder insulated?

No cylinder		Jacket with no gaps
No insulation		Solid insulation
Jacket with gaps		Don't Know

SECTION 4 - HEATING, LIGHTING & HOT WATER

17. What is your main heating fuel?

Mains Gas		Solid Fuel (Smokeless)
Electricity		Bottled Gas
Oil		LPG (Bulk)
Solid Fuel (Coal)

18. What is your main heating system?

Boiler and radiators		Room heaters or fires
Electric storage heaters		Other
Warm air system

19. Do you use a separate fire?

No		Yes, Gas
Yes, Electric		Yes, Solid Fuel

20. How is your main heating controlled? (Select all that apply)


Room Thermostat	Storage Heater Dials	Programmer/Timer	Thermostatic Radiator Valve

No controls		Thermostatic Radiator Valves
Programmer/Timer		Storage Heater Dials
Room Thermostat

21. How is your water heated? (Select all that apply)

From main heating system		Electric Immersion (off peak)
Gas instantaneous/combi boiler		Dual electric immersion
Electric instantaneous		Gas, oil or coal range
Electric immersion (on peak)		Back boiler

22. How is your water heating controlled? (Select all that apply)


Hot Water Tank Thermostat	Programmer/Timer

No controls		Programmer/Timer
On/Off		Hot Water Tank Thermostat

23. How old is your boiler?

Less than 5 years		Over 15 years
5 - 10 years		Don't Know
11 - 15 years

24. Which best describes your heating pattern?

Morning and evening, monday to friday; all day saturday and sunday
Morning and evening, monday to friday; most of the day saturday and sunday
Morning and evening, all week
All day, all week

25. Tick this box if your heating system is broken

26. What type of cooker do you have?

Gas		Gas hob with electric oven
Electric		Oil or coal range

27. How many low energy light bulbs do you have?

None		Most
One		All
Some		Don't Know

SECTION 5 - PERSONAL INFORMATION

28. How many people including yourself live in the household?

29. How many are under 16 years old

(Include any expected children if MATB1 maternity certificate has been issued)

30. Please give the date of birth of the youngest child (if any):
Day Month(1-12) Year

31. How many living in the household are over 60?

32. Please give the date of birth of the oldest household member:
Day Month(1-12) Year

33. Please identify the approximate household income (after tax and NI).
Choose whether you find it easiest to think in terms of weekly,
fortnightly or monthly income and then select the option on the
right that best fits the amount in that column.

Weekly	Fortnightly	Monthly
less than £40	less than £80	less than £173
£40 to £45	£80 to £90	£173 to £195
£45 to £50	£90 to £100	£195 to £217
£50 to £55	£100 to £110	£217 to £238
£55 to £65	£110 to £130	£238 to £282
£65 to £75	£130 to £150	£282 to £325
£75 to £80	£150 to £160	£325 to £347
£80 to £90	£160 to £180	£347 to £390
£90 to £100	£180 to £200	£390 to £433
£100 to £115	£200 to £230	£433 to £498
£115 to £130	£230 to £260	£498 to £563
£130 to £145	£260 to £290	£563 to £628
£145 to £160	£290 to £320	£628 to £693
£160 to £180	£320 to £360	£693 to £780
£180 to £205	£260 to £410	£780 to £888
£205 to £235	£410 to £470	£888 to £1018
£235 to £265	£470 to £530	£1018 to £1148
£265 to £300	£530 to £600	£1148 to £1300
£300 to £335	£600 to £670	£1300 to £1452
£335 to £375	£670 to £750	£1452 to £1625
£375 to £420	£750 to £840	£1625 to £1820
£420 to £475	£840 to £950	£1820 to £2058
£475 to £535	£950 to £1070	£2058 to £2318
more than £535	more than £1070	more than £2318

34. Does the householder or householder's partner receive any of the following benefits?
(Tick any that apply)

Attendance Allowance
Income Support
Housing Benefit
Disability Premium added to Housing Benefit or Council Tax Benefit
Incapacity Benefit
Disability Living Allowance
Pension Credit
Income Based Job Seekers Allowance
Job Seekers Allowance
Working Tax Credit (provided income on tax credit letter < £14,200)
Child Tax Credit (provided income on tax credit letter < £14,200)
War Disablement Pension (WDP)
Industrial Injuries Disablement Benefit (IIDB)
WDP (including constant attendance allowance or mobility supplement)
IIDB(including constant attendance allowance)
Council Tax Benefit (excluding single person reduction)

If you would like anyone who contacts you in the future to use a password,
please write it here:

SECTION 6- FUEL INFORMATION

35. Please specify who currently supplies your fuel

	Electricity	Gas
British Gas
Calor (LPG)
Eastern Electricity
Eastern Natural Gas
Northern Electric and Gas
Npower
PowerGen
Scottish Gas
Southern Electric/Gas
Other (please specify)

36. How do you pay for your electricity and gas?

	Credit/Account (e.g. monthly or quarterly bill or direct debit)	Pre-payment (e.g. coin or keycard meter)
A. Electricity
B. Gas

SECTION 7 - LANDLORD DETAILS

37. If you rent your property, please give details of your landlord

Name:

Address
House:

Street:

Town:

Postcode:

Telephone number (including code):

SECTION 8 - ADDITIONAL INFORMATION AND CONSENT

Tick below if you would like to receive further information on:

Debt advice Benefits Advice

If you have requested advice, or if you may be eligible for a partial or full grant towards home energy efficiency improvements, Northumberland Warm Zone may disclose your details to one or more relevant organisations who may contact you. If you do NOT wish your details to be disclosed to receive grants or advice, please tick here

The Northumbria Energy Efficiency Advice Centre will process this form on the Energy Saving Trust's behalf, and will send you your personalised report with information on how to reduce the energy costs in your home. The Energy Saving Trust may in future wish to send you further relevant information on energy efficiency or other products and services. The Energy Saving Trust may also disclose your details, if relevant, to other organisations who may wish to provide you with further relevant information on improving energy efficiency. If you do NOT wish to receive information from the Energy Saving Trust or to have your details disclosed to these organisations, please tick here

If you do not qualify for a grant, but you would like to receive an unconditional quote for any work you require, please tick here

And finally....

Submitting this form does not commit you at this stage to any work being carried out on your home, and if offered a grant or further advice can be accepted of declined as you choose

If submitting the form does not appear to work, use the back button on your browser to return to this page and try again, or print it off and send it to:

Northumberland Warm Zone
FREEPOST NEA13034, Blyth NE24 1BR

Warm Zones cic is registered in England (No. 4124262):
St Andrew's House, 90-92 Pilgrim St, Newcastle NE1 6SG.

If you are completing this online form for someone who doesn't live with you, please remember to enter their details. At any time you can clear all the selected values and start again by pressing this button: