Approved For Release 2003109110 : CIA-RDP96-00788 ROO 1700210032-7
Research Project
VA Hospital
Topeka, Kansas
(Revised 9/76)
Subject
ATTITUDES TOWARD DEkTH QUESTIONNAIRE
You are asked to complete the attached questionnaire, which contains
a set of statements frequently made about death. In each question,
you should check the category with which you agree most fully.
Items I through 11 ask the frequency you have certain thoughts, and
these may range from often to never. Items 12 through 30 ask the
degree to which you agree with each item, and your answers may range
from strongly agree to strongly disagree. This is a measure of per-
sonal belief. Obviously there are-no right or wrong answers.
Your participation is entirely voluntary, and you may feel free to
decline to complete the questionnaire. One purpose of the question-
naire is to determine whether certain answers are associated with
chemical dependency.
I have read the above and am willing to participate in the following
questionnaire.
(Signature)
Witnessed (if applicable)
Approved For Release 2003/09/10: CIA-RDP96-00 788 ROO 1700210032-7
Approved For Release 2003/09/10 : CIA-RDP96-00788ROO1700210032-7
THE 21,FCe,Y.TION REQU`-,'ST---'D ON @';:IS F05!,11 13 f,@@-ICIT'-U) U.'71',:; I AUTHORITY 07 T-ITL7-, 38, U.S. CODE, "VETERANS B1--NF-FITS",
I ',RT OF YOUR '1-tr7A7,!aTT PROCiA14, ALSO, THS RE-5=3
.,:.D 7."ILL BE U21-0 FOR =,11 APHA-31:1 TEST, ',"HICH TS P.-
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WILLI BE U:3"-M FOR RES'@ARCH3 TO ID@NTIFY ';,YS OF PROVIDING B-Sq-TER PATIa%TP QkRE. IT WILL NOT B-
USED FOR A@jy OTHER PURPOSE. 1)1',CLO3URE IS VOLUNTARY. h)AEVFR, FAILURE TO FURNISH THIS DIFORMATION WILL XkKE IT
MORE DIFFICUT;," FOR U3 IN YO',E,@ T;L--!ArE1!T PROGRAM. FAI.LU@ TO FURNISH THIS INFORMATION WILL HAVE 110 PDVERSE EFFE^.T
ON ANY BENLFITS-WHI CH YOU YAY BE i2l'T TLZD.
							
			OFTEN	SOMETIME	RARELY	NEVER	
I. I think about my own	eath.						
2. 1 think about the deat	h of						
loved ones.							
3. 1 think about dying ye	,ung.						
4. 1 think about the poss	ibility						
of my being killed on
street.	a city						
5. 1 have fantasies of my	own						
death.							
6. 1 think about death Ja
before I go to sleeD.	st						
7. 1 think of how I would	act						
if I knew I were to di
within a given period	e
of time.						
8. 1 think about how my	elatives						
would act and feel upo
death.	n my						
9. When I am sick I thinl	. about						
death.							
10. When I am outs1de dur:
lightning storm I thin	.ng a
k about						
the possibility of be
struck bylightning.	ing						
11. When I am in an automo	bile I						
think about the high
of traffic fatalities@	U-7-dence						
							
(continued next page)							
							
							
Revised 9/76
Appr-a-ed FzaaQelease 299 8-6 8 FOS ROM -71002. OPQ
Approved For Release 2003/09/10 CIA-RDP96-00788 ROO 1700210032-7
Page 2 - Continued from reverse side.
			STRONGUY
DISAGREE	SOMEWHAI
DISAGREE	SOMEWHA
AGREE	7 STRONGL)
AGREE	
12. 1 think_people should	first						
become concerned abou
when they are old.	: death						
13. 1 am much more concer	ned						
about death than thos
me.	e around						
14. Death hardly concerns	me.						
15. My general outlook 'u	,,t						
doesn't allow for mor
-- thoughts.	id						
16. The prospect of my ov	i death						
arouses anxiety in me							
The prospects of my o
depresses me.	wn death						
18. The prospect of the d	eath of						
my.loved ones arouses
in me.	anxiety						
19. The knowledge that I w	ill						
surely die does not im
way affect the conduc	any
of m						
life.
-
-							
=eai
20. 1 envision my
07;
- painful nightmarish ex	-h as a
perience	
.					
21. 1 am afraid of dying.							
22. 1 am afraid of being i	lead.-						
23. Many people become di	turbed.						
at the sight of a new
but it does not bother	grave
me.-						
24. 1 am disturbed when I
-	think						
esso.,
about the shortF	life.						
Thinking about death i
waste of time.	s a						
							
(continued page 3)
pAU=->jnn-17-7
VA ro" 6WW%%jW,1ea§e
MAR 1953 7051b
Approved For Release 2003/09/10 CIA-RDP96-00788ROO1700210032-7
Page 3
STRONGLY SOMEWHAI SOMEWHAT STRONGLY
DISAGREE DISAGREF AGREE AGREE
26. Death should not be
as a tragedy if it occurs
after a productive life.
27. The inevitable death of man
poses a serious challenge to
the meaningfulness of human
existence.
28. The death of the individual
is ultimately beneficial
because it facilitatES change
in society.
29. 1 have a desire to live on
after death.
30. The
question o whetler or
not there is a futurE life
worries me consideraFly.
-- --------------------------------
VA FORM ABP SO 2003109110 CiA-r-,LjP 90-00MR66 766tj DMm@,
Aj)CUjrLVEjffIeI
WAR 1933 7051 b 47FIG