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Home visit assessment form

This is a form designed for use by our staff when conducting home visits.

You can book one of our services here

The Form

Assessor Details

Assessor Name

Assessment Date

Tenant Details

Title

Last Name

Ethnicity

Select an Address

Local Authority

First Name

Date of Birth

Email

Phone

Borough

Notes on Client

Landlord Details

Title

Last Name

Phone

First Name

Email

Select an Address

Letting or Management Agency (if applicable)

Was the tenant provided with a "How to Rent" guide when moving in?

Yes

No

Doesn't remember

Was the tenant provided with a Deposit Protection Certificate when moving in?

Yes

No

Doesn't remember

Did the landlord provide any white goods appliances?

Notes on Property

EPC Details

Was the tenant provided with an EPC when moving in?

Yes

No

Doesn't remember

Does the property have an EPC?

Yes

No

EPC Rating

Why does the EPC not seem accurate?

Does the EPC seem accurate?

Yes

No

Have you engaged with the council on non-compliance?

If the property is F or G rated, has the landlord taken action to improve their property under MEES?

Property Details

Does the house feel excessively cold in the winter?

Yes

No

If yes, which rooms?

Does the house feel excessively hot in the summer?

Yes

No

If yes, which rooms?

Is there any damp/mould present in the property?

Yes

No

If yes, which rooms?

Is there a working carbon monoxide alarm?

Yes

No

Is there a valid gas safety certificate?

Yes

No

Is there a valid electrical condition inspection report?

Yes

No

Are there any problems with hot water or heating?

Yes

No

If yes, please note heating system, make and model

Are there any problems with water or water leaks?

Yes

No

If yes, please detail what and where

Are there any issues with ventilation?

Yes

No

If yes, please detail what and where

Are there any draughts?

Yes

No

If yes, please detail here

Are there any obvious basic repairs required?

Yes

No

If yes, please detail here

Fire Safety Properties

Are there working fire alarms in the property?

Yes

No

If the property is more than 2 floors, are the fire alarms interlinked?

Yes

No

Poor Condition Properties

Fill in this section if you feel that the tenant urgently needs assistance due to extreme poor condition of the property.

Do you think this property needs to be reported for enforcement?

Yes

No

Please detail any obvious structural problems with the property (e.g. cracks in walls)

Please detail any obvious electrical issues (e.g. broken plug sockets, exposed wiring)

Notes or comments

Evidence

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Do you have additional evidence that can't fit here?

Yes

If yes, where can they be found?

Additional notes or comments

LAD Funding

Do you think this tenant qualifies for LAD funding?

Yes

No

Building type

How is the property heated?

How many adults in total live in the home?

Loft type

Is the tenant single or part of a couple living together?

How many people aged 60-74 live in the home?

How many people aged 75 or older live in the home?

Is this property classed as a HMO?

Yes

No

How many children under 16 (under 18 if in full-time education) live at the address?

How many children aged 0-1 live in the home?

How many children aged 2-4 live in the home?

How many children of primary school age live in the home?

How many children of secondary school age live in the home?

Is there anyone pregnant in the home?

Yes

No

Child Benefit Number (if applicable)

Does anyone living within the home have any of the health conditions listed?

Yes - one of the conditions applies

No - none of the conditions apply

Does anyone else in the household receieve benefits or have an income that forms part of the household income assesmsment. This could be a spouse, partner or any other adults living in the property?

Yes

No

Title

Last name

First name

Date of Birth (dd/mm/yyyy)

Is there a second adult in the household in receipt of benefits or have an income that forms part of the household income assesmsment. This could be a spouse, partner or any other adults living in the property?

Yes

No

Title

Last name

First name

Date of Birth (dd/mm/yyyy)

Is there any other information about the household that may need to be considered?

What is the primary tenant's eligibility?

1 - Eligible due to receipt of a qualifying benefit

2 - Eligible based on residual income

3 - Eligible due to receipt of a qualifying benefit AND also based on residual income

Residual income (£)

Thanks for submitting!

Contact Us:

futurefithomes@selce.org.uk

020 4566 5764

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