CIA-RDP96-00788R001700210032-7

Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210032-7
Research Project
VA Hospital
Topeka, Kansas
(Revised 9/76)
Subject #
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 INFORMATION REQUESTED ON THIS FORM IS SOLICITED UNDER AUTHORITY OF TITLE 38, U.S. CODE, "VETERANS BENEFITS"
AND WILL BE USED FOR YOUR APHASIS SCAPINTING TEST, WHICH IS PART OF YOUR TREATMENT PROGRAM, ALSO, THE RESULTS
WILL BE USED FOR RESEARCH PURPOSES DESIGNED TO IDENTIFY WAYS OF PROVIDING BETTER PATIENT CARE. IT WILL NOT BE
USED FOR ANY OTHER PURPOSE. DISCLOSURE IS VOLUNTARY. HOWEVER, FAILURE TO FURNISH THIS INFORMATION WILL MAKE IT
MORE DIFFICULT FOR US IN YOUR TREATMENT PROGRAM. FAILURE TO FURNISH THIS INFORMATION WILL HAVE NO ADVERSE EFFECT
ON ANY BENEFITS WHICH YOU MAY BE ENTITLED.
OFTEN
SOMETIME
RARELY
NEVER
1. I think about my own death.
2.
I think about the death of
loved ones.
3.
I think about dying young.
4. I think about the possibility
of my being killed on
street.
a city
5.
I have fantasies of my own
death.
6.
I think about death just
before I go to sleep.
7.
I think of how I would act
if I knew I were to die
within a given period
of time.
8. I think about how my felatives
would act and feel upon my
death.
9. When I am sick I think
death.
about
10.
When I am outside during a
lightning storm I think about
the possibility of being
struck by lightning.
11.
When I am in an automobile I
think about the high incidence
of traffic fatalities.
(continued next page)
Revised 9/76
Approved For Release 2002/09/10 : CIA RDP06 00700R0017002020
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GPD

Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210032-7
1
Page 2 - Continued from reverse side.
STRONGLY SOMEWHAT SOMEWHAT STRONGLY
DISAGREE DISAGREE
AGREE
AGREE
12.
I think people should first
become concerned about death
when they are old.
13.
I am much more concerned
about death than those around
me.
14.
Death hardly concerns
me.
15. My general outlook just
doesn't allow for morbid
thoughts.
16.
The prospect of my own death
arouses anxiety in me
17. The prospects of my own death
depresses me.
18. The prospect of the death of
my loved ones arouses anxiety
in me.
19. The knowledge that I will
surely die does not in any
way affect the conduct of my
life.
20. I envision my own death as a
painful nightmarish experience.
21. I am afraid of dying.
22.
I am afraid of being dead.
23.
Many people become disturbed
at the sight of a new grave
but it does not bother me.
24. I am disturbed when I
think
about the shortness of life.
25.
Thinking about death
waste of time.
is a
(continued page 3)
..
VA FORM
MAR 1953
70516 DATAVeSHEET
For Release 2003/09/10 : CIA-RDP06 00788R001700210032-7
148 -10-82196-1
489-291
GPO

Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210032-7
Page 3
STRONGLY| SOMEWHAT SOMEWHAT STRONGLY
DISAGREE DISAGREE
AGREE
AGREE
26.
Death should not be regarded
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.
I have a desire to live on
after death.
30.
The question of whether or
not there is a future life
worries me considerably.
VA FORM
MAR 1953
7051b DATA SHEET
APPI
Please 2003/09/10 ."CIA-RDP90-00788R001
002100
498 -201