Gay/Lesbian/Transgender 
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Near-Death Experience (NDE)
Gay/Lesbian/Transgender Questionnaire Introduction

For those who are Gay/Lesbian/Bisexual/Transgender:

Please consider participating in the first Internet based study organized within the gay community.  There are many important lessons to be learned from understanding Near Death Experience (NDE).

All information shared as part of this study is confidential to the degree requested by you.  This study will involve completing an Internet questionnaire form regarding your experience (will take about 45 minutes).  This questionnaire is open to anyone who has been Gay/Lesbian/Bisexual/Transgender at any time in their life.  We welcome contributions from all individuals regardless of sexual orientation.  For those who are not Gay/Lesbian/Bisexual/Transgender, please contribute your experience in the "Share NDE" section with linked via the button on the left.  

For the purpose of this study, NDE is defined as:

“A lucid experience associated with perceived consciousness apart from the body occurring at the time of actual or threatened death”.

With your advance permission (from the Internet form) we would be happy to E-mail back your submission, with all questions on the Internet form and your responses.  You may then share your experience submission in written form with anyone you wish.  We regret there can be no other compensation for participation in this study.  Results of this study will be periodically published (anonymously) to this web site (a non-profit web site).  Thank you in advance for your willingness to participate in this important study!

This project is a collaboration of two major NDE researchers:

Dr. Liz Dale is a Clinical Psychologist, NDE researcher and author of a book regarding gay NDE.  Please contact Liz for further information about this study at lizdale1@juno.com.

Dr. Jeff is a Physician, and webmaster of this web site.  Dr. Jeff serves on the Board of Directors of IANDS (International Association for Near-Death Studies).  Please contact Dr. Jeff for further information about this study via E-mail at .

wpeC.jpg (800 bytes) NDE Questionnaire

    Thank you again for your willingness to share your NDE experience!  If you know any other NDE experiencers, please encourage them to share their experience as well.


Form Instructions:

1.    Please fill out the form below as completely and accurately as you can.  We will honor the confidentiality of your submission at the level you specify in the following form.
2.     It may be necessary to enter the same information in several boxes.  You may re-type the information (preferred, copy & paste as appropriate) or reference a previous question number containing the response to the current question (example): "see #7".
3.    Please do not forget to press the "Submit" button at the end or the information will be lost! 
4.    If you have time constraints, you may share in several partial submissions over time.  Complete only previously unsubmitted portions of the form each time. If you are sharing in this manner, please complete the last box (contact information) each time you submit.  This will allow us to consolidate all portions you have shared.
5.    After you press the submit button, a review of your responses to the questions will be shown.  A button will allow you to return to this page. 
The form will be blank, but all information will have been sent.  If you noted any errors, please fill out only the parts of the form to be corrected, and submit again.   If you have any questions or concerns please E-mail us.
6.    I wish the account of my experience to be placed in the NDERF archives.  I understand it may be read by students or researchers who have been approved by NDERF for use of the archives, and the co-investigators of this study (Dr. Liz Dale and Dr. Dr. Jeff, see above).  My account may be excerpted or used in full, or data may be drawn from it in conjunction with an NDERF approved study or project, including but not limited to lectures or educational programs relating to Near-Death Experience, or part of a published article, or in a book.  My name and any contact information will not be used unless I give express permission to do so. 
THANKS!!!

Name:

Postal   Address:

Telephone:
E-Mail:


Contact restrictions (if any) & instructions:

No contact whatsoever
A researcher approved by NDERF may contact me.  If so, I can still choose at that time not to be interviewed and not to participate.  I may change this approval for contact at any time.


If I approve of contact, the following are any restrictions or preferred method(s) of contact (if any):


Experience publication restrictions (if any) & instructions:

With any individual or organization approved by NDERF (website, media or publication):

Under no circumstances

Select (or de-select) as many below as apply:

Anonymously (without my name)

With my E-Mail address

With my name

With my address


Date of experience:


Age at time of experience:


Age now:


Location of experience (city or county, state, country if not U.S.A.):

You are biologically:
Female     Male

Sexual identity prior to experience (check the one best response):
Gay    Lesbian    Bisexual    Transgender    Heterosexual    Sexual identity not established    No response

Comments on sexual identity prior to experience:



Sexual identity currently (check the one best response):
Gay    Lesbian    Bisexual    Transgender    Heterosexual    Sexual identity not established    No response

Comments on sexual identity currently:



During your experience, were you aware of your own or others sexual identity?
No     Yes     Uncertain     No response
If yes or uncertain, describe.  Please include in detail all communications, interactions or understandings during your experience pertaining to sexual identity:



Did the experience change your sexual identity in any way or change the way you feel about your sexual identity?
No     Yes     Uncertain     No response
If yes or uncertain, describe.


Condition around the time of experience:

Clinical death (cessation of breathing or heart function or brain function)
Life threatening event, but not clinical death
Illness, trauma or other condition not considered life threatening
Other (briefly specify):


Circumstances around the time of experience (Check all that apply):

Accident Illness Surgery-related
Childbirth Heart attack Allergic reaction
Suicide attempt Combat Criminal attack
Other (briefly specify):


Status of health after experience:
Excellent      Good      Fair      Poor

Status of health now:
Excellent      Good      Fair      Poor


Did your experience include (check all that apply):

Out of body experience Presence of unearthly beings
Light Presence of deceased persons
Darkness A landscape or city
Void Boundary
Strong emotional tone Special Knowledge
Life review Vision of the future
Features consistent with your beliefs at the time
None of the above


Has your experience resulted in changes in any of the following (check as many as apply):

Personal relationships Belief system
Job or studies Physical aftereffects
Increased sensitivity, healing or psychic abilities Feelings about family, friends or society
Feelings about death Sense of life purpose
None of the above

Have these changes resulting from your experience been:
Positive      Disturbing      Mixed

Over time, did these changes resulting from your experience:
Increase      Decrease       Stay about the same

Your current principal occupation:


Your main interests and hobbies:


Your religious background at time of experience (Faith/denomination (or 'None'):
Conservative/fundamentalist        Moderate        Liberal


Your religious background currently (Faith/denomination (or 'None'):
Conservative/fundamentalist         Moderate        Liberal


Race (check as many as apply):
Caucasian    Black    Hispanic    Asian      Native American
Other:

Country of birth:


Country (ies) of family origin:


After your experience, did you consider the contents of your experience:
Wonderful    Frightening     Mixed

Highest level of education (1-12 for grades 1-12, then add 1 for each         additional year
of post High School education):

Were there any associated medications or substances with the potential to affect the experience? 
No     Yes     Uncertain     No response
   If yes or uncertain, please explain:

2.  Was the kind of experience difficult to express in words?
No     Yes     Uncertain     No response
   
If yes or uncertain, what was it about the experience that makes it hard to communicate?


3.  At the time of this experience, was there an associated life threatening event?
No     Yes     Uncertain     No response
   If yes or uncertain, describe:


4.  Please describe your experience using as much detail as you can and as much space as you need (scroll bars allow unlimited amount of writing):

5. What was your level of consciousness and alertness during the experience?

    Was the experience dream like in any way?

6.    Did you experience a separation of your consciousness from your body?
No     Yes     Uncertain     No response
   
If yes or uncertain, describe your appearance or form apart from your body.

7. What emotions did you feel during the experience?

    Please include your feelings, if relevant, to events you describe in your answers to the following questions.

8. Did you hear any unusual sounds or noises?

9. Did you pass into or through a tunnel or enclosure?
No     Yes     Uncertain     No response
   
If yes or uncertain, describe.

10. Did you see a light?
No     Yes      Uncertain     No response
    If yes or uncertain, describe.

11. Did you meet or see any other beings?
No     Yes      Uncertain     No response
   
If yes or uncertain, describe. Where were they? Did you know them? What was communicated?

12. Did you experience a review of past events in your life?
No     Yes     Uncertain     No response
   
Describe in detail.  Did you learn anything you did not previously know?  Did you learn anything that helped you live your life after the experience?

13. Did you observe or hear anything regarding people or events during your experience that could be verified later?
No     Yes     Uncertain     No response
    If yes or uncertain, describe. 
How did you verify this?

14. Did you see or visit any beautiful or otherwise distinctive locations, levels or dimensions?
No     Yes     Uncertain     No response
   
If yes or uncertain, describe.

15. Did you have any sense of altered space or time?
No     Yes     Uncertain     No response
    If yes or uncertain, describe.

16. Did you have a sense of knowing special knowledge, universal order and/or purpose?
No     Yes     Uncertain     No response
   
If yes or uncertain, discuss and share what you came to know.

17. Did you reach a boundary or limiting physical structure?
No     Yes     Uncertain     No response
   
If yes or uncertain, describe. Did you cross the boundary? If yes, describe. If no, did you have a sense of what would happen if you did cross the boundary?

18. Did you become aware of future events?
No     Yes     Uncertain     No response
   If yes or uncertain, describe.  Based on your life following the experience, how accurate was this awareness?

19. Were you involved in or aware of a decision regarding your return to the body?
No     Yes     Uncertain     No response
   
If yes or uncertain, describe, including your emotions at that time.

20. Did you have any psychic, paranormal or other special gifts following the experience you did not have prior to the experience?
No     Yes     Uncertain     No response
   If yes or uncertain, describe.

21. Did you have any changes of attitudes or beliefs following the experience?
No     Yes     Uncertain     No response
   
If yes or uncertain, describe.

22. How has the experience affected your relationships? Daily life? Religious practices etc.? Career choices?

23. Have you shared this experience with others?
No     Yes     Uncertain     No response
   
If yes, What were their reactions? Were they influenced in any way by your experience? How?

24. What emotions did you experience following your experience?

25. What was the best and worst part of your experience?

26. Is there anything else you would like to add concerning the experience?

27.    Has your life changed specifically as a result of your experience?
No     Yes     Uncertain     No response
    If yes or uncertain, and if not answered above, please describe:


28.
Following the experience, have you had any other events in your life, medications or substances which reproduced any part of the experience?
No     Yes     Uncertain     No response
    If yes or uncertain, describe.

29. Did the questions asked and information you provided accurately and comprehensively describe your experience?
No     Yes     Uncertain     No response
    Explain.

30.   Please offer any suggestions you may have to improve this questionnaire.  Are there any other questions we could ask to help you communicate your experience?

   Thanks!!!

WB01618_.gif (290 bytes) Remember to Submit completed form! 

Caution... Reset button will erase ALL data entered! 


Last revised: May 26, 2012

Copyright1999 by Dr. Jeff and Jody Long


e-mail:   Webmaster:  Jody A. Long


 

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