CIA-RDP96-00788R001700210035-4

Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210035-4
Monroe Institute of Applied Sciences
MEMO FROM ROBERT MONROE
P.O. Box 57
Afton, Virginia 22920
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 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, 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.
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 ONLY, AND FOR NO OTHER PURPOSE.
Signed
Date
Name (please print)
Address
Town and state
ZIP
Code # Assigned:
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 experiences that may change their
lives in certain ways. The attached scale provides information on your PROFILE OF
ADAPTATION TO LIFE (PAL), and will be used only to measure the effects of our pro-
grams over time. The information you provide will remain strictly confidential and
the results will be reported in group averages. You, of course, are free not to
participate if that is your choice.
Please complete this background information first. Then go on and complete the
PAL Scale items themselves. Your participation in this evaluation of our program
is 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?
(1)
None or rare cup
(Check one)
(4)
5 or more cups per day
34
DO YOU WATCH TV? (Check one)
(4)
3-4 hours per day
(1)
None or rarely
(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
(3)
6-7 hours
(5)
8 or more hours
36
OCCUPATION OR PROFESSION;
37
Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210035-4
Prog.
Subj #
3(80)
(3)
3-4 cups per day
(2)
About 1-2 cups per day