You are on page 1of 2

(Name of Your Cluster or Area): Neighbors Helping Neighbors

(N2N)
Survey
(Name of Your Cluster or Area) is exploring a national program for older adult residents, called
Neighbor to Neighbor (N2N). The purpose of the program is to support older residents so they can remain
in their homes as they age. Examples of help may include changing a light bulb or furnace filter, hanging
art work, taking in the mail, assistance with email or TV problems. Rides to medical appointments is being
handled by other community programs.
N2N is also a means for older residents to share their talents with others, such as tutoring or music
expertise. Helping one another across the generations is consistent with Restons vision as a place for all
ages and a way to ensure that (Name of Your Cluster or Area) remains a good place to grow up
and grow old.
This preliminary survey is completely voluntary and being used to gain an understanding on the kinds of
help needed. You can be a Service Recipient and receive help, or you can be a Service Volunteer and
provide help, or you can be both!
We will provide survey feedback and next steps in a future communication.
1. Please indicate your interest in participating in (Name of Your Cluster or Area) Neighbors
Helping Neighbors (N2N). Check all that apply.
a. __A Service Recipient (Help Needed)
b. __A Service Volunteer (Willing to Help)
c. __All of the above
d. __No interest

2. If you checked Service Volunteer please indicate which services you would be willing to provide.
(check one or more). These are just examples.
a. __Help in weather emergency
b. __Check on neighbors (make a phone call)
c. __Help neighbor with minor home repairs (install light bulbs, hang pictures, lift a heavy box, reach
high shelves)
d. __Provide neighbors with an occasional meal, or help to prepare a meal
e. __Help with a computer or technology problem
f. __Take in the mail or newspaper
g. __Leaf-raking or snow shoveling *
h. __Pet care *
i. __Share my talents (i.e., art, music, tutoring, etc.)
j. __Other __________________

3. If you checked Service Recipient, please indicate what services would be useful to receive (circle
one or more):
a. __Help in weather emergency
b. __Check on me (phone or visit) from time to time
c. __Provide minor home repairs (install light bulbs, hang pictures, lift a heavy box, reach high
shelves)
d. __Provide an occasional meal or help me prepare a meal
e. __Help with a computer or technology problem
f. __Take in the mail or newspaper
g. __Leaf-raking or snow shoveling *

h. __Pet care *
i. __Share my talents (i.e. art, music, tutoring)
j. __Other _______
* For certain items, a small payment/gratuity may be in order.
Please indicate any other thoughts or concerns you have below, or on the back:
---------------------------------------------------------------------

Name(s) of Participant(s)
Service Recipient (Help Needed)

Service Volunteer (Willing to Help)

__________

_________

_________

_________

_________

_________

House Number ______


Telephone __________

Email(s) ___________

Please circle your age: Under 55

55-65

Over 65

Note: If a high school student wishes to participate for community service credit, please provide name of
high school.
_______________

Please return by ______


Thank you for your response.

(Name) Coordinator, (Name of Your Cluster or Area) Neighbor to Neighbor (N2N)


Steering Committee, address, email, (XXX) XXX-XXXX.
For additional information on this program, contact Sharon Canner, Reston for a Lifetime,
sharon.canner8@gmail.com.
or Patricia Rohrer, Long Term Care Program Development Coordinator, Fairfax County Health
Department, Patricia.Rohrer@fairfaxcounty.gov, 703-246-8456.