1. Who are you requesting this locking cooker valve for? *

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2. Please provide a named contact who will be at the property and will be responsible for agreeing where the locking cooker valve is fitted. This is usually a carer or relative.

Please let us know this person's details: *

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3. Please let us know your own contact details:

 

4. Property visit details

YesNoDon't knowNot applicable
Is there a free-standing cooker?
Is there a built-in hob?
Has the landlord given permission to fit a self-locking cooker valve?
 

5. Is there any extra information that you think it would be helpful for us to know? For example, are there any access issues with the property?

 

6. Where did you hear about this scheme? (You can give more than one answer) *

 

7. OPTIONAL: Why does this person need a locking cooker valve?

This question is optional and your information will be made anonymous. We will use the data to help us target special interest groups and reach other people in need of this service more effectively.

 

8. SGN abides by the Data Protection Act 1998 (further details in our terms and conditions). *