Gas Capped Customer Survey

Colleague Name *

Customer Name *

Customer Email Address *

Customer Address *

How are you heating your home? *

Gas Combi Boiler

System Boiler

Are you able to afford to heat your home? *

Yes

Do you have any damp or mould in your property? *

Yes

Where is the damp located? *

Questions about your household

Is anyone in your home over the age of 65? *

Yes

Are there any children aged under 16 years old living in the household *

Yes

Is anyone in your home have a disability or long-term illness? *

Yes

Does anyone in your home rely on medical equipment in your home? *

Has anyone in your home gone through a recent bereavement, break-up or job loss? *

Yes

Do you have any issues with using any rooms in your home due to have a large quantity of belongings?

Is anyone in your home recovering from hospital treatment? *

Yes

Do you have any care or support needs? *

Yes

Are you living independently for the first time? *

Yes

Would you like support from our Tenancy Sustainment or Money Advisors from RBH to help with your winter energy costs? *

Yes

Do you need us to communicate with you via an interpreter? *

Yes

Language Preference

Any other comments

Consent for storing submitted data *

Yes, I give permission to store and process my data