ATTITUDES TOWARD DEATH QUESTIONNAIRE

• Document Type: CREST
• Collection: STARGATE
• Document Number (FOIA) /ESDN (CREST): CIA-RDP96-00788R001700210032-7
• Release Decision: RIFPUB
• Original Classification: K
• Document Page Count: 4
• Document Creation Date: November 4, 2016
• Document Release Date: December 4, 1998
• Sequence Number: 32
• Publication Date: September 1, 1976
• Content Type: PAPER

Approved For Release 2003/09/10 : CIA-RDP96-00788R001700210032-7
Research Project
VA Hospital
Topeka, Kansas
(Revised 9/76)
Subject 1/
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
T: L";'r'C ti! I.T ION RE L STED ON :..IS FOR!,! .3 N^.:IC I'. ED U.171,:; AUTHORITY OF TITLE 3, U.S. CODE, "VETERANS BENEFITS",
..:.D 7.IILL BE USED FOR YOUR APH.F.3I:; ,iIEG TEST, , '.ISH :S ?. RT OF YOUR 1Rr.AT vT PRGC3A.s" ALSO, THE RESULTS
WILL BE USED FOR RESEARCH FUR JS i D:SIQ ' D TO IDENTIFY AYS OF PROVIDING BETTER PATIa%T CARE. IT WILL NOT BE
USED FOR ANY OTHER PURPOSE. '_E1-,CLOSURE IS VOLUNTARY. h)AEVER, FAILURE TO FURNISH THIS DiFORMATION WILL MAKE IT
MORE DIFFICULT FOR US IN YOUR Ti:ii1:T