Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210032-7 Research Project Subject # VA Hospital Topeka, Kansas (Revised 9/76) ATTITUDES TOWARD DEATH 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 1 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-RDP96-00788R001700210032-7
Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210032-7 THE INFCAMATION REQUESTED ON & AND WILL Be USED FOR YOUR APHASI WILL BE USED FOR RESFARCH PURFQSES Ob. USED FOR ANY OTHER PURPOSE, MORE DIFFICULT FOR US IN YOUR TRiAT-ENT PACGRAM., ON ANY BENEFITS WHICH YOU May BE cNTITLED 1. QI think about my own . 2. I think about the death of loved ones. 3. I think about dying 4. I think about the posgibility of my being killed onja city street. c D i e § . S. 5. 1 have fantasies of m death. 6. I think about death jst before I go to sleep. 7. II think of how I would if I knew I were to dle within a given periodjof time. act 8. I think about how m would act and feel upon my death. 9. When I am sick I think about death. en 1 am outside dur{ng a lightning storm I thigk about the possibility of bejng struck by lightning. 10. 11. When I am in an autom@¢bile I think about the high jncidence of traffic fatalities (continued next page) Mh wm =~: DISCLOSURE IS VOLUNTARY. ie) FORM £3 GAQLICITED UNEY2 AUTHORITY OF TITLE 38, U.S. CODS, "VETERANS BENEFITS", ; iING TEST, WHICH [S PART OF YOUR TREATMENT PROCRAM, IGNED TO IDENTIFY {AYS OF PROVIDING ERTTER PATIENT CARE. ALSO, THE RESULTS If WILL NOT BE BKONEVER, FAILURE TO FURNISH THIS INFORMATION WILL MAKE IT FAILUR 5 TO FURNISH THIS INFORMATICN WILL EAVE NO ADVERSE EFFECT OFTEN NEVER és LY P| a _ Revised 9/76 -TwY¥ . O4S- HPO SR2 08k AOR 2H oPO
Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210032-7 Page 2 - Continued from reverse side, SOMEWHA'T SOMEWHAT STRONGL DISAGREE] DISAGREH AGREE AGREE 12. IL think people should] first become concerned abou death when they are old. 13. LI am much more concer about death than thosé around Ft me. 14. Death hard1l concerns 15. My general outlook jubt | doesn’t allow for morbid thoughts. 16. The prospect of my oO arouses anxiety in me 1/7. The prospects o my own deat depresses me. 18. The prospect of the déath of ff my loved ones arouses anxiety in me. 19. The knowledge that I surely die does not in any way affect the conduct of my ife. a o fo ct a be we ~ O. envision my own dea as a painful nightmarish experience 21. I am afraid of dying. 22. I am afraid of being ¢ 23. Many people become digturbed, | of at the sight of a new grave but it does not bothet me. 24. I am disturbed when T think || P| about the shortness of lite, | | . nKkilng about deat waste of time. (continued page 3) t4S “1821 y4-1 4u¥-291 aPo marisss 7O051b BRERA