Damp and mould Report date Tenant name Required Who is filling out this form? Required I am the tenant / live at the property Family member/ friend / neighbour Stoke-on-Trent City Council staff member Unitas staff member None of the above If you are not the tenant, please provide your name here If you are not the tenant, please provide your name here If you are not the tenant, please provide your name here If you are not the tenant, please provide your name here Property address Required Postcode Lookup Please provide the contact details for who is best for us to speak to about this report. Telephone number Required Email address Please tell us how many bedrooms are in the property? Required Please tell us how many people live in the property? Required Please tell us whereabouts the damp and mould has been found... Required Walls Ceiling Floor Windows Other If other, please tell us more... In which room has the damp or mould been found? Required Is anyone at the property: (tick all that apply) Required A new born baby A young child (aged 0 - 5 years old) Elderly None of the above Does anyone living at the property have a health condition that may be affected by damp, mould or condensation e.g. asthma, weakened immune system, allergies or recent surgery? If so, please state below. If this does not apply then please put ‘N/A’ Required Upload a photo here... Drop files here or click to upload. Choose a file… If you are unable to upload a photo, on a scale of 1-5 (5 being the worst), how would you rate any damp, mould or condensation currently present? 1 2 3 4 5