MONROE INSTITUTE OF APPLIED SCIENCES - MEMO FROM ROBERT MONROE

• Document Type: CREST
• Collection: STARGATE
• Document Number (FOIA) /ESDN (CREST): CIA-RDP96-00788R001700210035-4
• Release Decision: RIFPUB
• Original Classification: K
• Document Page Count: 2
• Document Creation Date: November 4, 2016
• Document Release Date: December 4, 1998
• Sequence Number: 35
• Publication Date: January 1, 1976
• Content Type: MEMO

Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210035-4
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 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
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
Fkom time to time, people become ,involved in expexLences that may change the -&
.P.%va in certain ways. The attached ~scate ptovLde4 in6atmat on on yawn. PROFILE OF
ADAPTATION TO LIFE (PAL), and w tt be used on!y to measure the e66ecto a6 out pto-
gtam6 oven time. The An6otmatI.on you ptov,ide will temain stAic.ty con6 dentiae and
the tesu to wilt be tepotted in group avetage6. you, o6 couture, ate 6tee not to
pa- tLc,Lpate - that i6 your choice.
Please comp.Lete th i o baclzgtaund in4atmation 4L't t. Then go on and comp.ee to the
PAL Scaee -items themsetve4. YOWL pakti.ci.pation in thL evaluation ob our pnagnam
,us very much apptec,i.ated.
BACKGROUND INFORMATION:
Name Today's Date
Street Phone
City & State Zip
YOUR MARITAL STATUS (Check one)
(1) Currently married
(2) Separated, divorced, widowed
(3) Never married
SEX (Check one)
(1) Male (2) Female
AGE
EDUCATION (Check one)
(1) Less than high school (3) Some college
(2) High school graduate (4) College graduate
Type of degree )
HEIGHT: feet inches
WEIGHT: mounds
27
28-30
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
(2) 5-6 hours
(3)- 6-7 hours
OCCUPATION OR ForlRei
(5) 8 or more hours
36
37
210035-4 3(80)
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