Approved For Release 2003109110 : CIA-RDP96-00788 ROO 1700210035-4
Monroe Institute of Applied Sciences
P.O. Box 57
Afton, Virginia 22920
MEMO FROM ROBERT MONROE
We invite you to participate in a study designed to measure the kinds of
changes that take place in people who receive the M-5000 Training. All
trainees are being asked to complete four Profile of Adaptation of Life
(PAL) Questionnaires - one prior to initial training, and three fol,lowing
training. From these questionnaires, we will be able to determine the
kinds of changes that take place in people's adaptation to living over
a 12-month follow-up period. Collaborating in this research with me is
Dr. Robert Ellsworth, a research psychologist at the Veterans Hospital
in Salem, Virginia, who will be sending you the follow-up questionnaires.
The questionnaire that you are asked to complete pertains to some aspects
of your adaptation to life and your life style. Because this material is
personal, steps have been taken to insure your right to privacy. For
example, your name will not appear on the questionnaire. only a code
number will be assigned to your questionnaire.
If you agree to participate in the follow-up part of the study, siqn and
return this form at the same time you send in your questionnaire.
Dr. Ellsworth will send you the follow-up PAL Questionnaires for you to
complete and return to him. All questionnaires will remain in his research
files, and will be destroyed at the end of the study. The results will
be reported only by group averages. If you are interested in the results
of this study when available, check below.
Your decision to participate in the follow-up study is entirely voluntary
on your part. Your participation will help us understand better the effects
of the M-5000 training on people's adaptation to life. For this reason,
your participation is important to us and greatly appreciated.
I CONSENT TO PARTICIPATE IN THIS STUDY UNDER THE CONDITIONS THAT MY
IDENTITY WILL REMAIN ANONYMOUS AND THAT THE RESULTS WILL BE USED FOR
RESEARCH PURPOSES ONLY9 AND FOR NO OTHER PURPOSE.
Signed
Date
Name (please print)
Address
Town and state
Code # Assigned:
Approved For Release 2003/09/10 : CIA-RDP96-00788 ROO 1700210035-4
Approved For Release 2003/09/10 : CIA-RDP96-00788ROO1700210035-4
BACKGROUND INFORMATION TO PAL SCALE
Fkom time to time, peopte become invotved in expexiences that may change thei't
tiva in ceAtain ways. The attached scate ptovidm in6atmation on yout PROFILE OF
ADAPTATION TO LIFE (PAL), and witt be uzed onty to meazute the e66ects o6 out pto-
g@Law oveA time. The in6oAmation you p.,tovide wiU temain stiictty con6identiat and
the kesuttz witt be tepotted in gtoup aveAage6. Vou, o6 coume, ate 6,tee not to
paAticipate iA that i6 you& choice.
Ptea.se comptete thi6 backg&ound in4o@unation 4imt. Then go on and comptete the
PAL Scate items theynzetvez. Vou)i pakticipation in th" evatuation o@ ouA pAogAam
" ve&y much appteciated.
BACKGROUND INFORMATION:
Name
Street
City & State
Today's Date
Phone
Zip
YOUR MARITAL STATUS (Check one)
(1) Currently married
(2) Separated, divorced, widowed
(3)- Never married
SEX (Check one)
(1)_ Male (2)
AGE
Female
EDUCATION (Check one)
(1) Less than high school
(2)- High school graduate
HEIGHT: feet inches
WEIGHT: ---Pounds
DO YOU SMOKE CIGARETTES? (Check one)
(1) Not at all
(2)-- About 1/2 pack per day
(3) Some college
(4) College graduate
@-Type of degree
(3) About 1 pack per day
(4)- Over I pack per day
HOW MUCH COFFEE DO YOU DRINK EACH DAY? (Check one)
(1) None or rare cup (3) 3-4 cups per day
(2)- About 1-2 cups per day (4)- 5 or more cups per day
DO YOU WATCH TV? (C4eck one)
0 ) None or rarely (4)
(2) Less than 1 hour per day (5)
(3)- 1-2 hours per day
AVERAGE HOURS OF SLEEP PER NIGHT (Check one)
(1) 4-5 hours (4)
(2) 5-6 hours (5)-
(3)- 6-7 hours
3-4 hours per day
5 or more hours per day
7-8 hours
8 or more hours
17-22
23
24
25-26
27
28-30
31-32
33
34
35
36
OCCUPATIONAOR PROEUSI 37
pproved For Reiease 2663tOW10 m ClA-R1)P96-00788R001W10035-4 3(80)
L( - -
Prog. STbj-#- - -