| * = required field |
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| Contact one first name*: |
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| Contact one surname*: |
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| Contact two first name (not required): |
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| Contact two surname (not required): |
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| Residential Street Address*: |
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| Town*: |
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| Postcode*: |
(N.B. postcode of house, not Post Box) |
| Postal address: |
(if different to Residential) |
| Dwelling*: |
House Unit/Flat Other (please specify) |
| Occupancy*: |
Owner Tenant |
| Phone*: |
(after hours)
(business hours)
(mobile) |
| Email address: |
(Email is our quickest and most sustainable form of communication with you.) |
| Alternative email address: |
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| Length of residence*: |
How long have you been living at this address? *years/months |
| Adults & Children: |
How many people live in your house? Adults? Teenagers? Children? |
| Was your household directly recruited or invited into C500 by another person? Yes No |
| If yes, what is the full name of the person who recruited you? |
| What would you say was the key way you found out about the C500 Project? |
Project Flyer Project Poster Shire Newsletter Community Presentation
Website Word of mouth Local Newspaper Pledge Postcard Other (please specify) |
| YOUR ENERGY USE AT HOME |
| 10. Who is your electricity supplier (retailer)? |
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| 11. Who is your gas supplier (retailer)? |
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| 12. Are you subscribed to a Green Power scheme? |
Electricity? Yes No Gas? Yes No |
13. What is your main form of home heating?
The heating source that you use the most. |
Electric heater Gas heater Wood combustion heater |
| ACTION TO REDUCE HOUSEHOLD ENERGY CONSUMPTION |
| After reading the two statements below, tick the box that represents your initial reaction: |
| 15. “By implementing simple actions at home, I believe that it is possible to reduce our household energy consumption by at least 15% within the next 12 months”. |
| Strongly Agree Agree Unsure Disagree Strongly disagree |
| 16. “If every household in Australia reduced its energy consumption by 15%, this would make a big difference to Australia’s overall energy consumption and greenhouse gas emissions”. |
| Strongly Agree Agree Unsure Disagree Strongly disagree |
| 17. Select one of the following statements that best describes your household in relation to ACTION taken already to reduce energy use. |
| A. Champions |
We have done everything we possibly can and there is little room for improvement |
| B. Firing Up |
We have taken many steps to reduce energy use, but there is still room for improvement |
| C. Getting Going |
We have started taking steps in the right direction to reduce energy consumption |
| D. Just a Matter of Time |
We are thinking and talking about it, but haven’t started yet. |
| E. Who knows what will happen? |
We haven’t really given it much thought. |
18. There are many benefits to reducing your household energy consumption - some you may already have in mind.
Please rank your top 3 motivations (1 being most important) for reducing your household energy consumption. |
| General home improvement |
1 2 3 |
| Save money on electricity and gas bills |
1 2 3 |
| Personal comfort … feeling warmer in winter/cooler in summer |
1 2 3 |
| Reduce our household greenhouse gas emissions and our impact on climate change |
1 2 3 |
| Other |
1 2 3 – please specify |
19. To date, what have been the biggest barriers to reducing your energy consumption?
(Tick any number of boxes that appear relevant to you). |
| Lack of knowledge and information |
Not sure which actions are the best to take |
| Too costly |
Other people in my family |
| My house is too hard to change |
My busy life, and lack of time |
| Other reasons, please specify here |
| 20. Anything else you would like to add?
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| I have read and understood the Privacy Statement (read here) |
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