Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210035-4 __ Monroe Institute of Applied Sciences 00 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 following 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 l2-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, sign 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. 1 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 ONLY, AND FOR NO OTHER PURPOSE. Signed Date Name (please print) Address Town and state Code # Assigned: Ce pe nen Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210035-4
Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210035-4 BACKGROUND INFORMATION TO PAL SCALE From time to time, people become involved in expertences that may change thetr Lives in certain ways. The attached seake provides information on your PROFILE OF ADAPTATION TO LIFE (PAL), and wikt be used only to measure the effects of our pro- grams over time. The information you provide wikh remain strictly confidential and the results will be reported in group averages. You, of course, are gree not to participate 44 that 4s your choice. Pkease complete this background information fist. Then go on and complete the PAL Scale items themselves. Your participation in this evaluation of our program 4h very much appreciated. BACKGROUND INFORMATION: Name Today's Date | 17-22 Street Phone City & State Zip YOUR MARITAL STATUS (Check one) (1) Currently married (2) Separated, divorced, widowed (3) Never married 23 SEX (Check one) (1) Male (2) Female 24 AGE 25-26 EDUCATION (Check one) (1) Less than high school (3) Some college (2). High school graduate (4) College graduate (Type of degree ) 27 HEIGHT: feet inches 28-30 WEIGHT: pounds 31-32 DO YOU SMOKE CIGARETTES? (Check one) (1) Not at all (3) About 1 pack per day (2) About 1/2 pack per day (4) Over 1 pack per day 33 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 - 34 DO YOU WATCH TV? (Check one) | (1) None or rarely (4). 3-4 hours per day (2) Less than 1 hour per day (5) 5 or more hours per day 35 (3) 1-2 hours per day AVERAGE HOURS OF SLEEP PER NIGHT (Check one) (1). 4-5 hours (4) 7-8 hours (2). 5-6 hours (5) 8 or more hours ; (3) 6-7 hours 36 . 37 OCCUPATION, QR -BROF BSS Siease-2003/09/10--CIA-RDP96-00788RUU1719210035-4 3(80) ee ee