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border-width: medium" width="179"><a href="index.htm"> <img border="0" id="img1" src="images/button16.jpg" height="20" width="170" alt="Strona g&#322;ówna NDERF" fp-style="fp-btn: Glass Rectangle 5; fp-font-color-normal: #000080; fp-proportional: 0; fp-orig: 0" fp-title="Strona g&#322;ówna NDERF" onmouseover="FP_swapImg(1,0,/*id*/'img1',/*url*/'images/button17.jpg')" onmouseout="FP_swapImg(0,0,/*id*/'img1',/*url*/'images/button16.jpg')" onmousedown="FP_swapImg(1,0,/*id*/'img1',/*url*/'images/button18.jpg')" onmouseup="FP_swapImg(0,0,/*id*/'img1',/*url*/'images/button17.jpg')"></a><br><a href="nderf_ndes.htm"> <img border="0" id="img2" src="images/button19.jpg" height="20" width="170" alt="Nades&#322;ane prze&#380;ycia (NDE)" fp-style="fp-btn: Glass Rectangle 5; fp-font-color-normal: #000080; fp-proportional: 0; fp-orig: 0" fp-title="Nades&#322;ane prze&#380;ycia (NDE)" onmouseover="FP_swapImg(1,0,/*id*/'img2',/*url*/'images/button1A.jpg')" onmouseout="FP_swapImg(0,0,/*id*/'img2',/*url*/'images/button19.jpg')" onmousedown="FP_swapImg(1,0,/*id*/'img2',/*url*/'images/button1B.jpg')" onmouseup="FP_swapImg(0,0,/*id*/'img2',/*url*/'images/button1A.jpg')"></a><br><a href="Share%20NDE%20Polish.htm"> <img border="0" id="img3" src="images/button1C.jpg" height="20" width="170" alt="Napisz o swoim prze&#380;yciu" fp-style="fp-btn: Glass Rectangle 5; fp-font-color-normal: #000080; fp-proportional: 0; fp-orig: 0" fp-title="Napisz o swoim prze&#380;yciu" onmouseover="FP_swapImg(1,0,/*id*/'img3',/*url*/'images/button1D.jpg')" onmouseout="FP_swapImg(0,0,/*id*/'img3',/*url*/'images/button1C.jpg')" onmousedown="FP_swapImg(1,0,/*id*/'img3',/*url*/'images/button1E.jpg')" onmouseup="FP_swapImg(0,0,/*id*/'img3',/*url*/'images/button1D.jpg')"></a></td> <td style="border-style: none; border-width: medium"><p align="center"><b><font face="Arial" color="#0066CC"><span style="font-size: 36.0pt; mso-bidi-font-size: 10.0pt; font-family: Arial; mso-fareast-font-family: Times New Roman; mso-bidi-font-family: Times New Roman; mso-ansi-language: EN-US; mso-fareast-language: EN-US; mso-bidi-language: HE"> Podziel siê swoim prze¿yciem z pogranicza Smierci. </b></span></font></td> </tr> </table> <p align="center"><strong><font color="#008080" face="Calligrapher" size="6">(To najwa¿niejsza czêSæ tej strony!)&nbsp; </font></strong></p> <p align="center"><strong><font color="#993399"><big><big>Ankieta NDE</big></big></font></strong></p> <p align="center"><font face="verdana, arial, helvetica"><strong> <font color="#ff0000" face="Sherwood" size="6">&nbsp;</font><font color="#ff0000" size="6" face="Arial"> </font></strong></font><font face="Arial"><strong> <font color="#ff0000" face="Arial" size="4">Potrzebujemy ochotników, którzy pomog¹ nam w t³umaczeniu materia³ów do stron w jêzykach afrykañskich, Srodkowo-wschodnich, hebrajskim, indyjskim, tajwañskim i wszystkich innych, w jakich mo¿ecie nam pomóc.&nbsp;&nbsp;</font></strong></font><strong><big><big><font color="#993399" face="Cornerstone"><br> <br> &nbsp;</font></big></big></strong></p> ?<<!-- function FrontPage_Form1_Validator(theForm) { if (theForm.PageValidation.value == "") { alert("Please enter a value for the \"PageValidation\" field."); 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theForm.PageValidation.focus(); return (false); } if (theForm.Date_of_NDE.value == "") { alert("Please enter a value for the \"Date of experience (near top of survey)\" field."); theForm.Date_of_NDE.focus(); return (false); } if (theForm.Date_of_NDE.value.length < 1) { alert("Please enter at least 1 characters in the \"Date of experience (near top of survey)\" field."); theForm.Date_of_NDE.focus(); return (false); } if (theForm.Date_of_NDE.value.length > 99999) { alert("Please enter at most 99999 characters in the \"Date of experience (near top of survey)\" field."); theForm.Date_of_NDE.focus(); return (false); } if (theForm.Age_at_NDE.value == "") { alert("Please enter a value for the \"Age at time of experience (near top of survey)\" field."); theForm.Age_at_NDE.focus(); return (false); } if (theForm.Age_at_NDE.value.length < 1) { alert("Please enter at least 1 characters in the \"Age at time of experience (near top of survey)\" field."); theForm.Age_at_NDE.focus(); return (false); } if (theForm.Age_at_NDE.value.length > 99999) { alert("Please enter at most 99999 characters in the \"Age at time of experience (near top of survey)\" field."); theForm.Age_at_NDE.focus(); return (false); } if (theForm.Age_Now.value == "") { alert("Please enter a value for the \"Age now (near top of survey)\" field."); theForm.Age_Now.focus(); return (false); } if (theForm.Age_Now.value.length < 1) { alert("Please enter at least 1 characters in the \"Age now (near top of survey)\" field."); theForm.Age_Now.focus(); return (false); } if (theForm.Age_Now.value.length > 99999) { alert("Please enter at most 99999 characters in the \"Age now (near top of survey)\" field."); theForm.Age_Now.focus(); return (false); } if (theForm.Location_of_NDE.value == "") { alert("Please enter a value for the \"Location of experience (near top of survey)\" field."); theForm.Location_of_NDE.focus(); return (false); } if (theForm.Location_of_NDE.value.length < 1) { alert("Please enter at least 1 characters in the \"Location of experience (near top of survey)\" field."); theForm.Location_of_NDE.focus(); return (false); } if (theForm.Location_of_NDE.value.length > 99999) { alert("Please enter at most 99999 characters in the \"Location of experience (near top of survey)\" field."); theForm.Location_of_NDE.focus(); return (false); } if (theForm.Current_Occupation.value == "") { alert("Please enter a value for the \"Your current principal occupation (near top of survey)\" field."); theForm.Current_Occupation.focus(); return (false); } if (theForm.Current_Occupation.value.length < 1) { alert("Please enter at least 1 characters in the \"Your current principal occupation (near top of survey)\" field."); theForm.Current_Occupation.focus(); return (false); } if (theForm.Current_Occupation.value.length > 99999) { alert("Please enter at most 99999 characters in the \"Your current principal occupation (near top of survey)\" field."); theForm.Current_Occupation.focus(); return (false); } if (theForm.County_Of_Birth.value == "") { alert("Please enter a value for the \"Country of birth (near top of survey)\" field."); theForm.County_Of_Birth.focus(); return (false); } if (theForm.County_Of_Birth.value.length < 1) { alert("Please enter at least 1 characters in the \"Country of birth (near top of survey)\" field."); theForm.County_Of_Birth.focus(); return (false); } if (theForm.County_Of_Birth.value.length > 99999) { alert("Please enter at most 99999 characters in the \"Country of birth (near top of survey)\" field."); theForm.County_Of_Birth.focus(); return (false); } if (theForm.Highest_Education.selectedIndex < 0) { alert("Please select one of the \"Highest level of education (near top of survey)\" options."); theForm.Highest_Education.focus(); return (false); } if (theForm.The_Experience.value == "") { alert("Please enter a value for the \"3. Please describe your experience using as much detail as you \" field."); theForm.The_Experience.focus(); return (false); } if (theForm.The_Experience.value.length < 1) { alert("Please enter at least 1 characters in the \"3. Please describe your experience using as much detail as you \" field."); theForm.The_Experience.focus(); return (false); } if (theForm.The_Experience.value.length > 999999) { alert("Please enter at most 999999 characters in the \"3. Please describe your experience using as much detail as you \" field."); theForm.The_Experience.focus(); return (false); } if (theForm.Level_of_consciousness_and_alertness.value == "") { alert("Please enter a value for the \"4. At what time during the experience were you at your highest \" field."); theForm.Level_of_consciousness_and_alertness.focus(); return (false); } if (theForm.Level_of_consciousness_and_alertness.value.length < 1) { alert("Please enter at least 1 characters in the \"4. At what time during the experience were you at your highest \" field."); theForm.Level_of_consciousness_and_alertness.focus(); return (false); } if (theForm.Level_of_consciousness_and_alertness.value.length > 99999) { alert("Please enter at most 99999 characters in the \"4. At what time during the experience were you at your highest \" field."); theForm.Level_of_consciousness_and_alertness.focus(); return (false); } return (true); } //-->?<<form method="POST" onSubmit---- onSubmit---- onSubmit---- onSubmit---------------- onSubmit---- onSubmit---- onSubmit------ onSubmit------ onSubmit---- onSubmit---- onSubmit---- onSubmit---- onSubmit---- onSubmit---- onSubmit---- onSubmit---- onSubmit---- onSubmit---- action="../_vti_bin/shtml.exe/Polish/Share%20NDE%20Polish.htm" onSubmit="return FrontPage_Form1_Validator(this)" language="JavaScript" name="FrontPage_Form1" webbot-action="--WEBBOT-SELF--"> <!--webbot bot="SaveResults" u-file="../_private/form_results2.txt" s-format="TEXT/TSV" s-label-fields="FALSE" b-reverse-chronology="FALSE" s-builtin-fields startspan S-Email-Format="TEXT/TSV" S-Email-Address="blueheron78@yahoo.com" B-Email-Label-Fields="TRUE" --><input TYPE="hidden" NAME="VTI-GROUP" VALUE="0"><!--webbot bot="SaveResults" endspan i-checksum="43374" --> <p align="center"><strong><font color="#993399" face="Cornerstone"><big> <big>W zarysie:</big></big></font></strong></p> <p><font face="Arial"><strong><font color="#008080">Relacje z pogranicza Smierci (NDE) mog¹ byæ przesy³ane:&nbsp;</font></strong></font></p> <font face="Arial"><strong><font color="#008080">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</font><font color="#f75609">&nbsp;&nbsp;&nbsp; 1.&nbsp;&nbsp;&nbsp; Poprzez formularz na stronie NDERF </font></strong> <font color="#f75609"><strong>(preferowane).</strong></font> </font> <p><font face="Arial"><strong><font color="#f75609">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 2.&nbsp;&nbsp;&nbsp; Przez e-mail (adres na dole ka¿dej strony).&nbsp;&nbsp;</font></strong></font></p> <p><font face="Arial"><strong><font color="#008080">&nbsp;Choæ wielce doceniamy Wasz wk³ad zwi¹zany z przes³aniem Waszej relacji, niestety z ¿alem zawiadamiamy, ¿e nie wyp³acamy wynagrodzeñ pieniê¿nych za z³o¿one relacje osobom, które je przesy³aj¹.&nbsp; Zachowujemy poufnoSæ w stopniu okreSlonym przez osobê wysy³aj¹c¹ swoj¹ relacjê.&nbsp;</font></strong></font></p> <p><font face="Arial"><font color="#008080"><strong>W ankiecie mamy kilkanaScie pytañ</strong></font><strong><font color="#008080">, lecz chcemy równie¿ zarejestrowaæ aspekty Twojego doSwiadczenia nieporuszone w tych¿e pytaniach.&nbsp; Mamy nadzieje, ¿e te bêd¹ modyfikowane z up³ywem czasu by pozwoliæ nam lepiej zrozumieæ NDE i podobne doSwiadczenia.&nbsp; Wype³nienie ankiety zajmie min. oko³o 30 minut.&nbsp;</font></strong></font></p> <p align="justify"><font face="Arial"><font color="#008080"><strong>Twoja chêæ podzielenia siê swoimi prze¿yciami jest dla nas bardzo wa¿na w powodzeniu tego projektu.&nbsp; </strong></font><strong><font color="#008080"> Wyra¿amy z góry wdziêcznoSæ i podziêkowanie wszystkim, którzy siê nimi z nami dziel¹.&nbsp;</font></strong></font></p> <p align="center"><font color="#f75609" face="Arial"><strong><big>Wype³nij formularz</big></strong></font></p> <p align="center"><strong><font color="#ff8000" face="Arial"><br> </font><font color="#b700b7" face="Arial"><big>Instrukcje:</big></font></strong></p> <p align="left"><strong><font face="Arial"><font color="#0000ff">1.&nbsp;&nbsp;&nbsp; Proszê wype³niæ poni¿szy formularz&nbsp; jak najdok³adniej odpowiadaj¹c na jak najwiêksz¹ liczbê pytañ.&nbsp; </font><font color="#ff0000">Zachowujemy poufnoSæ Twojej relacji zgodnie z okreSlonym przez Ciebie poziomem.&nbsp;<br> </font><font color="#0000ff"><br> 2.&nbsp;&nbsp;&nbsp;&nbsp; Mo¿liwe, ¿e bêdzie konieczne wpisanie tej samej informacjê w kilku rubrykach. Mo¿esz w tym wypadku przepisaæ informacjê (preferowane, choæ funkcja &#39;wytnij/wklej równie¿ mo¿liwa). Czasami zostaniesz odes³any do poprzedniego pytania zawieraj¹cego odpowiedx na bie¿¹ce, np. : &quot;patrz #7&quot;.&nbsp;<br> <br> </font><font color="#ff0000">3.&nbsp; </font><font color="#0000ff">&nbsp; </font> <font color="#ff0000">Nie zapomnij nacisn¹æ przycisku &quot;WySlij&quot; gdy skoñczysz wype³nianie ankiety. W przeciwnym wypadku informacje bêd¹ stracone!&nbsp;&nbsp;</font><font color="#0000ff"><br> <br> 4.&nbsp;&nbsp;&nbsp; JeSli jesteS ograniczony czasowo, mo¿esz wys³aæ swoj¹ ankietê w kilku oddzielnych czêSciach. W tym wypadku wype³niaj tylko pytania wczeSniej niewype³nione. Pamiêtaj proszê jednak o wype³nieniu ostatniego pytania (tabelki) - informacji o kontakcie z Tob¹ za ka¿dym razem. To pozwoli nam z³o¿yæ wszystkie czêSci w jedn¹.&nbsp;&nbsp;</font></font></strong></p> <p align="left"><strong><font face="Arial"><font color="#0000ff"><br> 5.&nbsp;&nbsp;&nbsp; Po wciSniêciu przycisku &quot;WySlij&quot;, zobaczysz swoje odpowiedzi na pytania. Przycisk pozwoli Ci powróciæ do formularza. Formularz bêdzie pusty, lecz bêdzie to znaczy³o, ¿e informacja zosta³a wys³ana.&nbsp; JeSli zauwa¿ysz jakiekolwiek b³êdy, wype³nij jeszcze raz te czêSci, które maj¹ byæ poprawione i wySlij formularz jeszcze raz. JeSli masz jakieS pytania, proszê&nbsp; <a href="mailto:nderf@nderf.org">Napisz do nas e-mail</a>.<br> <br> 6.&nbsp;&nbsp;&nbsp; Chcê, ¿eby moja relacja zosta³a umieszczona w archiwum NDERF.&nbsp;Bêdzie ona mog³a byæ czytana przez studentów i badaczy upowa¿nionych przez NDERF do wgl¹du w archiwum. Moja relacja mo¿e byæ podzielona na fragmenty, przytaczana w ca³oSci b¹dx mog¹ z niej byæ wyci¹gane konkretne informacje w projektach i badaniach zatwierdzonych przez NDERF (w³¹czaj¹c w to wyk³ady, programy edukacyjne dotycz¹ce NDE, wydawane artyku³y, relacje opublikowane w ksi¹¿ce). Moje imiê i nazwisko nie bêdzie u¿ywane, chyba, ¿e na to pozwolenie.&nbsp; </font><font color="#ff0000">DZIÊKUJÊ!!!</font></font></strong></p> <p class="MsoNormal" align="center" style="text-align: left"><b> <span style="font-family:Arial;color:blue">1.&nbsp;&nbsp;&nbsp; Please fill out the form below as completely and accurately as you can.&nbsp; Please carefully consider your responses prior to making them.</span><span style="font-family:Arial;color:red"><br> </span><span style="font-family:Arial;color:blue"><br> 2.&nbsp;&nbsp;&nbsp;&nbsp; It may be necessary to enter the same information in several boxes.&nbsp; You may re-type the information (preferred: copy &amp; paste as appropriate) or reference a previous question number containing the response to the current question (example): &quot;see #7&quot;.&nbsp; <br> &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; We understand there are a number of questions that may ask the same concept in several different ways.&nbsp; This survey is a combination of the most validated and respected questions regarding near death experiences from the top researchers in the world.&nbsp; ALL your responses, even to similarly worded questions, are meaningful, and extremely important for our understanding.<br> <br> 3.&nbsp;&nbsp; The questions that are in </span> <span style="font-family:Arial;color:red">red</span><span style="font-family: Arial;color:blue"> require responses.&nbsp; This is very important& you will not be able to send any information at all until all questions in </span> <span style="font-family:Arial; color:red">red</span><span style="font-family:Arial;color:blue"> have been answered!&nbsp; If you did not respond to one or several </span> <span style="font-family:Arial;color:red">red</span><span style="font-family:Arial;color:blue"> questions, when you press the  Submit button at the end of the form, an error page will appear indicating the question(s) that need answered before your information can be sent.&nbsp; <i>All questions with radio option buttons</i> (&quot;<input type="radio" name="Intro_Button" value="Intro Button">&quot;) <i>require a response</i>.&nbsp; Please fill out all text box (&quot;<input type="text" name="Intro_Text_Box" size="20">&quot;) questions to the best of your ability, but be aware that <i>the only text boxes where response is absolutely required have </i> </span><i><font color="#FF0000"><span style="font-family:Arial;"> red</span></font></i><span style="font-family:Arial;color:blue"><i> lettering immediately above the box</i>. <br> <br> </span><span style="font-family:Arial;color:red">4.&nbsp; </span> <span style="font-family:Arial;color:blue">&nbsp; </span> <span style="font-family:Arial;color:red">Please do not forget to press the &quot;Submit&quot; button at the end or the information will be lost!</span><span style="font-family:Arial;color:blue">&nbsp;<br> <br> 5.&nbsp;&nbsp;&nbsp; After you press the submit button upon completing the form, a review of your responses to the questions will be shown.&nbsp; A button will allow you to return to this page.&nbsp; The form will be blank, but all information will have been sent.<br> <br> 6.&nbsp;&nbsp;&nbsp; I wish the account of my experience to be placed in the NDERF archives.&nbsp; I understand it may be read by students or researchers who have been approved by NDERF for use of the archives.&nbsp; 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.&nbsp; My name or identifying information will not be used unless I give express permission to do so.&nbsp; </span> <span style="font-family:Arial;color:red">THANKS!!!</span></b></p> <p class="MsoNormal" align="center" style="text-align: left"><B><strong><font face="Arial" color="#FF0000">7.&nbsp; To prevent spammers and other inappropriate uses of this form, we have a special request:<br> &nbsp;&nbsp;&nbsp;&nbsp; Please type &quot;fox&quot; (case sensitive) in the first question immediately below, labeled as a Page Validation Question:</font></strong></b></p> <p class="MsoNormal" align="center" style="text-align: left"><strong> <font face="Arial" color="#FF0000"> =================================================================================================================</font></strong></p> <p class="MsoNormal" align="center" style="text-align: left"><B> <font size="5" face="Arial" color="#FF0000">1.&nbsp; Page Validation Question: Type &quot;fox&quot; in the box: </font><font face="Arial" size="4" color="#FF0000"> &nbsp;<!--webbot bot="Validation" s-display-name="PageValidation" s-data-type="String" b-allow-letters="TRUE" b-value-required="TRUE" i-minimum-length="3" i-maximum-length="4" s-validation-constraint="Equal to" s-validation-value="fox" --><input type="text" name="PageValidation" size="14" tabindex="1" style="border: 1px solid #008080; padding-left: 4px; padding-right: 4px; padding-top: 1px; padding-bottom: 1px" maxlength="4"></font><font color="#FF0000" face="Arial" size="5"> </font></b></p> <table border="1" width="523" height="142"> <tr> <td valign="middle" align="right" height="22" width="95"><b> <font face="Arial">Language:</font></b></td> <td valign="middle" align="left" height="22" width="432"><font face="Arial"> &nbsp;<input type="text" name="Language" size="60"></font></td> </tr> <tr> <td valign="middle" align="right" height="22" width="95"><b> <font face="Arial">Name:</font></b></td> <td valign="middle" align="left" height="22" width="432"><font face="Arial"> &nbsp;<input type="text" name="Name" size="60"></font></td> </tr> <tr> <td valign="middle" align="right" height="44" width="95"> <p align="right"><b><font face="Arial">Postal&nbsp;&nbsp; Address:</font></b></td> <td valign="middle" align="left" height="44" width="432"><font face="Arial"> &nbsp;<textarea rows="3" name="Address" cols="51"></textarea></font></td> </tr> <tr> <td valign="middle" align="right" height="22" width="95"><b><font face="Arial">Telephone:</font></b></td> <td valign="middle" align="left" height="22" width="432"><font face="Arial"><input type="text" name="Telephone" size="60"></font></td> </tr> <tr> <td valign="middle" align="right" height="22" width="95"><b><font face="Arial">E-Mail:</font></b></td> <td valign="middle" align="left" height="22" width="432"><font face="Arial"><input type="text" name="E_Mail" size="60"></font></td> </tr> </table> <p><font face="Arial"><b><font color="#000080"><br> Contact restrictions (if any) &amp; instructions:</font></b><br> <input type="radio" value="No contact whatsoever" name="Contact_researcher"><b>No contact whatsoever</b><br> <input type="radio" name="Contact_researcher" value="NDERF approved researcher may contact me" checked><b>A researcher approved by NDERF may contact me.&nbsp; If so, I can still choose at that time not to be interviewed and not to participate.&nbsp; I may change this approval for contact at any time.</b><b><font color="#000080"><br> <br> <br> If I approve of contact, the following are any restrictions or preferred method(s) of contact (if any):</font></b></font></p> <p><font face="Arial"> <textarea rows="3" name="restrictions_or_preferred_methods_of_contact" cols="80"></textarea></font></p> <B> <P><font face="Arial" color="#000080"><br> Experience publication restrictions (if any) &amp; instructions: </font> </P> <table border="1" width="520" height="293"> <tr> <td width="210" height="287"><font face="Arial"><b>With any individual or organization approved by NDERF (website, media or publication):</b></font><p><b><font face="Arial"><font color="#FF0000">*</font><font color="#0000FF">NOTE:</font><font color="#FF0000"> Please make sure your web browser and e-mail service do not place </font><a href="mailto:nderf@nderf.org"><font color="#0000FF">nderf@nderf.org</font></a><font color="#0000FF"> </font><font color="#FF0000">or </font><a href="mailto:blueheron78@yahoo.com"><font color="#0000FF">blueheron78@yahoo.com</font></a><font color="#FF0000"> in spam, delete or reject status - otherwise we can't contact you.&nbsp; Also, we never send <u>attachments</u>.&nbsp; Do NOT open <u>attachments</u> from either of these e-mails because they contain viruses and are spoofing (not from us)!</font></font></b></td> <td width="298" height="287"><b><font face="Arial" size="4" color="#008000">WHERE PUBLISH</font></b><p><font face="Arial"> <input type="checkbox" name="Publish_no_circumstances" value="Under no circumstances"><b>Under no circumstances</b></font></p> <p><font face="Arial"> <B> <input type="checkbox" name="Publish_on_website" value="On Website"></b></font><b><font face="Arial">Website only</font></b></p> <p><font face="Arial"> <B> <input type="checkbox" name="Publish_total_permission" value="Total Permission" checked></b></font><b><font face="Arial">Media, publication, and website (Will notify if a part of the story is used other than the website so long as we have a current e-mail address)</font></b></p> <p><font face="Arial"> <B> <input type="checkbox" name="Publish_ask_permission" value="Ask permission"></b></font><b><font face="Arial">Please ask permission to use the story in places other than the website.&nbsp; If e-mail is not kept current (bounces), a grant of permission is assumed.</font></b></p> <p><b><font face="Arial" size="4" color="#008000">HOW PUBLISH</font></b></p> <p><font face="Arial"><b><font size="4">Select (or de-select) as many below as apply: </font><br> </b><br> <input type="checkbox" name="Publication_Anon" value="Anonymously (without my name)"><b>Anonymously (without my name)</b></font></p> <p><font face="Arial"> <input type="checkbox" name="Publication_email" value="With my E-Mail address" checked><b>With my E-Mail address</b></font></p> <p><font face="Arial"> <input type="checkbox" name="Publication_Name" value="With my name" checked><b>With my name (first name and last initial)</b></font></p> <p><font face="Arial"> <input type="checkbox" name="Publication_Address" value="With my address" checked><b>With my address</b></font></p> </td> </tr> </table></b> <p><font face="Arial" color="#000080"><strong><br> </strong> </font> <font face="Arial"><strong><font color="#FF0000">Date of experience: </font> <br></strong> &nbsp;<!--webbot bot="Validation" s-display-name="Date of experience (near top of survey)" b-value-required="TRUE" i-minimum-length="1" i-maximum-length="99999" --><input name="Date_of_NDE" size="40" maxlength="99999"><br><br> <font color="#FF0000"> <b>Age at time of experience:</b></font><br> &nbsp;<!--webbot bot="Validation" s-display-name="Age at time of experience (near top of survey)" b-value-required="TRUE" i-minimum-length="1" i-maximum-length="99999" --><input name="Age_at_NDE" size="40" maxlength="99999"><br> <br> <font color="#FF0000"> <b>Age now:</b></font><br> &nbsp;<!--webbot bot="Validation" s-display-name="Age now (near top of survey)" b-value-required="TRUE" i-minimum-length="1" i-maximum-length="99999" --><input name="Age_Now" size="40" maxlength="99999"><br> <br><strong><font color="#FF0000">Location of experience (city or county, state, country if not U.S.A.):</font><br></strong> <!--webbot bot="Validation" s-display-name="Location of experience (near top of survey)" b-value-required="TRUE" i-minimum-length="1" i-maximum-length="99999" --><textarea cols="80" name="Location_of_NDE" rows="5"></textarea></font></p> <p><font face="Arial"><font color="#FF0000"><strong>You are:</strong></font> <br> &nbsp;<input name="Gender" type="radio" value="Female" checked><strong>Female &nbsp;&nbsp;&nbsp; </strong><input name="Gender" type="radio" value="Male"><strong>Male</strong></font></p> <p><font face="Arial" color="#FF0000"><strong>Condition around the time of experience (select best choice):</strong></font></p> <table border="1" width="510"> <tr> <td width="500"><font face="Arial"> <input type="radio" name="Condition_around_the_time_of_experience" value="Clinical death (cessation of breathing or heart function or brain function)" checked><b>Clinical death (cessation of breathing or heart function or brain function)</b></font></td> </tr> <tr> <td width="500"> <input type="radio" name="Condition_around_the_time_of_experience" value="Life threatening event, but not clinical death"><font face="Arial"><b>Life threatening event, but not clinical death</b></font></td> </tr> <tr> <td width="500"> <input type="radio" name="Condition_around_the_time_of_experience" value="Illness, trauma or other condition not considered life threatening"><font face="Arial"><b>Illness, trauma or other condition not considered life threatening</b></font></td> </tr> <tr> <td width="500"> <input type="radio" name="Condition_around_the_time_of_experience" value="Other"><font face="Arial"><b>Other (briefly specify):</b> <textarea rows="3" name="Other_condition_around_the_time_of_experience" cols="54"></textarea></font></td> </tr> </table> <p><font face="Arial"><br> <strong><font color="#FF0000">Circumstances around the time of experience (Check all that apply):</font></strong></font></p> <table border="1" width="509"> <tr> <td width="159"><font face="Arial"><b> <input type="checkbox" name="Circumstances_Accident" value="Accident">Accident</b></font></td> <td width="159"><font face="Arial"><b> <input type="checkbox" name="Circumstances_Illness" value="Illness">Illness</b></font></td> <td width="159"><font face="Arial"><b> <input type="checkbox" name="Circumstances_Surgery_related" value="Surgery-related">Surgery-related</b></font></td> </tr> <tr> <td width="151"><font face="Arial"><b> <input type="checkbox" name="Circumstances_Childbirth" value="Childbirth">Childbirth</b></font></td> <td width="159"><font face="Arial"><b> <input type="checkbox" name="Circumstances_Heart_attack" value="Heart attack">Heart attack</b></font></td> <td width="177"><font face="Arial"><b> <input type="checkbox" name="Circumstances_Allergic_reaction" value="Allergic reaction">Allergic reaction</b></font></td> </tr> <tr> <td width="151"><font face="Arial"><b> <input type="checkbox" name="Circumstances_Suicude_attempt" value="Suicide attempt">Suicide attempt</b></font></td> <td width="159"><font face="Arial"><b> <input type="checkbox" name="Circumstances_Combat" value="Combat">Combat</b></font></td> <td width="177"><font face="Arial"><b> <input type="checkbox" name="Circumstances_Criminal_attack" value="Criminal attack">Criminal attack</b></font></td> </tr> <tr> <td width="499" colspan="3"> <input type="checkbox" name="Circumstances_Direct_head_injury" value="Direct head injury"><font face="Arial"><b>Direct head injury&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <input type="checkbox" name="Circumstances_Other" value="Other circumstances around the time of experience">Other (briefly specify):<br> <textarea rows="3" name="Circumstances_Other_Explain" cols="54"></textarea></b></font></td> </tr> </table> <p><font face="Arial"><strong> <br> <font color="#FF0000">Did your experience include (check all that apply):</font></strong></font></p> <table border="1" width="510"> <tr> <td width="225"><b><font face="Arial"> <input type="checkbox" name="Experience_Include_OBE" value="Out of body experience"><font size="2">Out of body experience</font></font></b></td> <td width="269"><b><font face="Arial"> <input type="checkbox" name="Experience_Include_Unearthly_beings" value="Presence of unearthly beings"><font size="2">Presence of unearthly beings</font></font></b></td> </tr> <tr> <td width="225"><font face="Arial"><b> <input type="checkbox" name="Experience_Include_Light" value="Light"><font size="2">Light</font></b></font></td> <td width="269"><font face="Arial"><b> <input type="checkbox" name="Experience_Include_Deceased_persons" value="Presence of deceased persons"><font size="2">Presence of deceased persons</font></b></font></td> </tr> <tr> <td width="225"><b><font face="Arial" size="2"> <input type="checkbox" name="Experience_Include_Darkness" value="Darkness">Darkness</font></b></td> <td width="269"><b><font face="Arial" size="2"> <input type="checkbox" name="Experience_Include_Landscape_or_city" value="A landscape or city">A landscape or city</font></b></td> </tr> <tr> <td width="225"><b><font face="Arial" size="2"> <input type="checkbox" name="Experience_Include_Void" value="Void">Void</font></b></td> <td width="269"><b><font face="Arial" size="2"> <input type="checkbox" name="Experience_Include_Boundary" value="Boundary">Boundary</font></b></td> </tr> <tr> <td width="225"><b><font face="Arial" size="2"> <input type="checkbox" name="Experience_Include_Strong_emotional_tone" value="Strong emotional tone">Strong emotional tone</font></b></td> <td width="269"><b><font face="Arial" size="2"> <input type="checkbox" name="Experience_Include_Special_knowledge" value="Special Knowledge">Special knowledge</font></b></td> </tr> <tr> <td width="225"><b><font face="Arial" size="2"> <input type="checkbox" name="Experience_Include_Life_review" value="Life review">Life review</font></b></td> <td width="269"><b><font face="Arial" size="2"> <input type="checkbox" name="Experience_Include_Vision_future" value="Vision of the future">Vision of the future</font></b></td> </tr> <tr> <td width="500" colspan="2"><b><font face="Arial" size="2"> <input type="checkbox" name="Experience_Include_Features_consistent_belief" value="Features consistent with your beliefs at the time">Features consistent with your beliefs at the time</font></b></td> </tr> <tr> <td width="500" colspan="2"> <input type="checkbox" name="Experience_Include_Religious_or_spiritual_leaders" value="Presence of religious or spiritual leaders"><b><font size="2" face="Arial">Presence of religious or spiritual leaders (Jesus, Buddha, etc.)</font></b></td> </tr> <tr> <td width="500" colspan="2"><b><font face="Arial" size="2"> <input type="checkbox" name="Experience_Include_None_above" value="None of the above">None of the above</font></b></td> </tr> </table> <p><font face="Arial"><strong><br> <font color="#FF0000">Your current principal occupation:</font>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <!--webbot bot="Validation" s-display-name="Your current principal occupation (near top of survey)" b-value-required="TRUE" i-minimum-length="1" i-maximum-length="99999" --> <textarea rows="3" name="Current_Occupation" cols="80"></textarea><br> <font color="#FF0000"><br> Your religious background at time of experience (Faith/denomination, or 'None'):</font><br> &nbsp;<input type="radio" name="Religious_Before" value="Conservative/fundamentalist" checked>Conservative/fundamentalist&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <font color="#FF0000"> <input type="radio" name="Religious_Before" value="Moderate"></font>Moderate&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <font color="#FF0000"> <input type="radio" name="Religious_Before" value="Liberal"></font>Liberal<br> <textarea rows="3" name="Religious_Before_Explain" cols="80"></textarea> <br> <font color="#FF0000"><br> Your religious background currently (Faith/denomination, or 'None'):</font><br> &nbsp;<input type="radio" name="Religious_Changes_After" value="Conservative/fundamentalist" checked>Conservative/fundamentalist&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <font color="#FF0000"> <input type="radio" name="Religious_Changes_After" value="Moderate"></font>Moderate&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <font color="#FF0000"> <input type="radio" name="Religious_Changes_After" value="Liberal"></font>Liberal<br> <textarea rows="3" name="Religious_After_Explain" cols="80"></textarea><br> <font color="#FF0000"><br> Race (check as many as apply):</font><br> <input type="checkbox" name="Race_Caucasian" value="Caucasian">Caucasian&nbsp;&nbsp;&nbsp; <input type="checkbox" name="Race_Black" value="Black">Black&nbsp;&nbsp;&nbsp; <input type="checkbox" name="Race_Hispanic" value="Hispanic">Hispanic&nbsp;&nbsp;&nbsp; <input type="checkbox" name="Race_Asian" value="Asian">Asian&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <input type="checkbox" name="Race_Native_American" value="Native American">Native American<br> <input type="checkbox" name="Race_Other" value="Other">Other: <textarea rows="2" name="Race_Other_Explain" cols="60"></textarea><br> <br> <font color="#FF0000">Country of birth:</font><br> &nbsp;<!--webbot bot="Validation" s-display-name="Country of birth (near top of survey)" b-value-required="TRUE" i-minimum-length="1" i-maximum-length="99999" --><textarea rows="2" name="County_Of_Birth" cols="60"></textarea><br> <br> <font color="#FF0000">During your experience, did you consider the contents of your experience (NOT the possible life-threatening event that led up to the experience) to be:</font><br> &nbsp;<input type="radio" name="Ex_Feel" value="Wonderful" checked>Wonderful&nbsp;&nbsp;&nbsp; <input type="radio" name="Ex_Feel" value="Frightening">Frightening&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="Ex_Feel" value="Mixed">Mixed <br> <br> <font color="#FF0000">Highest level of education (Scroll down and select best response, non-USA respondents please make best guess of answer most equivalent to your education level):</font></strong> <br> &nbsp;<!--webbot bot="Validation" s-display-name="Highest level of education (near top of survey)" b-value-required="TRUE" --><select size="5" name="Highest_Education"> <option value="1st Grade">1st Grade</option> <option value="2nd Grade">2nd Grade</option> <option value="3rd Grade">3rd Grade</option> <option value="4th Grade">4th Grade</option> <option value="5th Grade">5th Grade</option> <option value="6th Grade">6th Grade</option> <option value="7th Grade">7th Grade</option> <option value="8th Grade">8th Grade</option> <option value="9th Grade">9th Grade</option> <option value="10th Grade">10th Grade</option> <option value="11th Grade">11th Grade</option> <option value="12th Grade (High School Graduate, or Equivalent)">12th Grade </option> <option value="High School + 1 year">High School + 1 year</option> <option value="High School + 2 years">High School + 2 years</option> <option value="High School + Three Years">High School + Three Years</option> <option value="College Graduate (4 years) or Equivalent">College Graduate (4 years) or Equivalent </option> <option value="College Graduate (4 years) + 1 year">College Graduate (4 years) + 1 year </option> <option value="College Graduate (4 Years) + 2 Years (Masters Degree)">College Graduate (4 Years) + 2 Years (Masters Degree) </option> <option value="College Graduate (4 Years) + 3 Years">College Graduate (4 Years) + 3 Years </option> <option value="College Graduate (4 Years) + 4 Years (Doctorate)">College Graduate (4 Years) + 4 Years (Doctorate) </option> <option value="College (4 Years) + More Than 4 Years Post College">College (4 Years) + More Than 4 Years Post College </option> </select><br><br> </font><b> <font face="Arial" color="#FF0000">1</font><font face="Arial"><font color="#FF0000">.&nbsp; Was the kind of experience difficult to express in words?</font><br></font></b><font face="Arial"> <input name="Difficult_to_express_experience" type="radio" value="No" checked><strong>No &nbsp;&nbsp;&nbsp; </strong><input name="Difficult_to_express_experience" type="radio" value="Yes"><strong>Yes&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="Difficult_to_express_experience" value="Uncertain">Uncertain<br>&nbsp;&nbsp;&nbsp; </strong><b>If yes or uncertain, what was it about the experience that makes it hard to communicate?<br><textarea cols="80" name="What_made_experience_difficult_to_communicate" rows="5"></textarea></b></font></p> <p><font face="Arial"><font color="#FF0000"><b>2</b></font><b><font color="#FF0000">.&nbsp; At the time of this experience, was there an associated life threatening event?</font> <br></b> <input name="Associated_life_threatening_event" type="radio" value="No" checked><strong>No &nbsp;&nbsp;&nbsp; </strong><input name="Associated_life_threatening_event" type="radio" value="Yes"><strong>Yes&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="Associated_life_threatening_event" value="Uncertain">Uncertain<br></strong><b>&nbsp;&nbsp; If yes or uncertain, describe:<br> <textarea cols="80" name="Associated_life_threatening_event_Explain" rows="5"></textarea><br> <br> <font color="#FF0000">3.&nbsp; 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):</font><br> &nbsp;<!--webbot bot="Validation" s-display-name="3. Please describe your experience using as much detail as you can..." b-value-required="TRUE" i-minimum-length="1" i-maximum-length="999999" --><textarea rows="20" name="The_Experience" cols="80"></textarea></b></font></p> <p><font face="Arial"><b><font color="#FF0000">4.&nbsp; </font> <strong> <font color="#FF0000">At what time </font><font color="#0000FF">during</font><font color="#FF0000"> the experience were you at your highest level of </font> </strong><font color="#FF0000">consciousness and alertness?</font><br> &nbsp;<!--webbot bot="Validation" s-display-name="4. At what time during the experience were you at your highest level of consciousness and alertness?" b-value-required="TRUE" i-minimum-length="1" i-maximum-length="99999" --><textarea cols="80" name="Level_of_consciousness_and_alertness" rows="5"></textarea><br> <br> <font color="#FF0000">5.&nbsp; How did your highest level of consciousness and alertness </font><font color="#0000FF">during</font><font color="#FF0000"> the experience compare to your normal every day consciousness and alertness?</font><br> <input type="radio" name="Highest_level_conscious_vs_normal" value="More consciousness and alertness than normal" checked>More consciousness and alertness than normal<br> <input type="radio" name="Highest_level_conscious_vs_normal" value="Normal consciousness and alertness">Normal consciousness and alertness<br> <input type="radio" name="Highest_level_conscious_vs_normal" value="Less consciousness and alertness than normal">Less consciousness and alertness than normal<br> <br> &nbsp;&nbsp;&nbsp; If your highest level of consciousness and alertness <font color="#0000FF">during</font> the experience was different from your normal every day consciousness and alertness, please explain:<br> <textarea cols="80" name="Level_of_consciousness_and_alertness_Difference" rows="5"></textarea><br> <font color="#FF0000"><br> 6.&nbsp; Were your thoughts speeded up?</font><br> <input type="radio" name="Were_your_thoughts_speeded_up" value="Incredibly fast" checked>Incredibly fast<br> <input type="radio" name="Were_your_thoughts_speeded_up" value="Faster than usual">Faster than usual<br> <input type="radio" name="Were_your_thoughts_speeded_up" value="Neither">Neither<br> <br> <font color="#FF0000">7.&nbsp; Were your senses more vivid than usual?<br> </font> <input type="radio" name="Were_your_senses_more_vivid_than_usual" value="Incredibly more so" checked>Incredibly more so<br> <input type="radio" name="Were_your_senses_more_vivid_than_usual" value="More so than usual">More so than usual<br> <input type="radio" name="Were_your_senses_more_vivid_than_usual" value="Neither">Neither<br> <br> </b></font><strong> <span style="font-size: 12.0pt; font-family: Arial; color: #FF0000">8.&nbsp; Did your vision differ in any way from your normal, everyday vision (in any aspect, such as clarity, field of vision, colors, brightness, depth perception degree of solidness/transparency of objects, etc.)?<br> </span></strong><font face="Arial"> &nbsp;<input name="Did_your_vision_differ_in_any_way_from_normal" type="radio" value="No" checked><strong>No &nbsp;&nbsp;&nbsp; </strong> <input name="Did_your_vision_differ_in_any_way_from_normal" type="radio" value="Yes"><strong>Yes&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="Did_your_vision_differ_in_any_way_from_normal" value="Uncertain">Uncertain</strong><b><br> <strong>&nbsp;&nbsp;&nbsp; </strong>If yes or uncertain, describe.<br> <textarea cols="80" name="Describe_vision_difference" rows="5"></textarea><br> </b></font><strong> <span style="font-size: 12.0pt; font-family: Arial; color: #FF0000"><br> 9.&nbsp; Did your hearing differ in any way from your normal, everyday hearing (in any aspect, such as clarity, ability to recognize source of sound, pitch, loudness, etc.)?</span></strong><font face="Arial"><b><br> </b> &nbsp;<input name="Did_your_hearing_differ_in_any_way_from_your_normal_hearing" type="radio" value="No" checked><strong>No &nbsp;&nbsp;&nbsp; </strong> <input name="Did_your_hearing_differ_in_any_way_from_your_normal_hearing" type="radio" value="Yes"><strong>Yes&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="Did_your_hearing_differ_in_any_way_from_your_normal_hearing" value="Uncertain">Uncertain<br> &nbsp;&nbsp;&nbsp; </strong><b>If yes or uncertain, describe.&nbsp;&nbsp; <textarea cols="80" name="Describe_hearing_difference" rows="5"></textarea></b></font></p> <p><font face="Arial"><font color="#FF0000"><strong>10.&nbsp; </strong></font> <b><font color="#FF0000">Did you experience a separation of your consciousness from your body?</font> <br></b> <input name="Separation_consciousness_from_body" type="radio" value="No" checked><strong>No &nbsp;&nbsp;&nbsp; </strong><input name="Separation_consciousness_from_body" type="radio" value="Yes"><strong>Yes&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="Separation_consciousness_from_body" value="Uncertain">Uncertain</strong><b><br><br> <font color="#FF0000">11.&nbsp; Did you feel separated from your physical body?</font><br> <input type="radio" name="Did_you_feel_separated_from_your_physical_body" value="Clearly left the body and existed outside it" checked>Clearly left the body and existed outside it<br> <input type="radio" name="Did_you_feel_separated_from_your_physical_body" value="Lost awareness of the body">Lost awareness of the body<br> <input type="radio" name="Did_you_feel_separated_from_your_physical_body" value="Neither">Neither</b></font></p> <p><font face="Arial"><strong>12.&nbsp; </strong><b> What emotions did you feel <font color="#0000FF">during</font> the experience?<br> <textarea cols="80" name="What_emotions_did_you_feel" rows="5"></textarea></b><br> <font color="#FF0000"><b><br> 13.&nbsp; Did you have a feeling of peace or pleasantness?<br> </b></font><b> <input type="radio" name="Did_you_have_a_feeling_of_peace_or_pleasantness" value="Incredible peace or pleasantness" checked>Incredible peace or pleasantness<br> <input type="radio" name="Did_you_have_a_feeling_of_peace_or_pleasantness" value="Relief or calmness">Relief or calmness<br> <input type="radio" name="Did_you_have_a_feeling_of_peace_or_pleasantness" value="Neither">Neither<br> <br> </b><font color="#FF0000"><b>14.&nbsp; Did you have a feeling of joy?<br> </b></font><b> <input type="radio" name="Did_you_have_a_feeling_of_joy" value="Incredible joy" checked>Incredible joy<br> <input type="radio" name="Did_you_have_a_feeling_of_joy" value="Happiness">Happiness<br> <input type="radio" name="Did_you_have_a_feeling_of_joy" value="Neither">Neither</b></font></p> <p><strong><font face="Arial" color="#FF0000">15</font></strong><font face="Arial"><font color="#FF0000"><strong>.&nbsp; </strong> </font><b><font color="#FF0000">Did you pass into or through a tunnel or enclosure?</font><br></b> <input name="Pass_into_or_through_tunnel_or_enclosure" type="radio" value="No" checked><strong>No &nbsp;&nbsp;&nbsp; </strong><input name="Pass_into_or_through_tunnel_or_enclosure" type="radio" value="Yes"><strong>Yes&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="Pass_into_or_through_tunnel_or_enclosure" value="Uncertain">Uncertain<br>&nbsp;&nbsp;&nbsp; </strong><b>If yes or uncertain, describe.<br><textarea cols="80" name="Describe_tunnel_or_enclosure" rows="5"></textarea></b></font></p> <p><font face="Arial"><font color="#FF0000"><strong>16.&nbsp; </strong></font> <b> <font color="#FF0000">Did you see a light?</font><br></b> <input name="See_a_light" type="radio" value="No" checked><strong>No &nbsp;&nbsp;&nbsp; </strong><input name="See_a_light" type="radio" value="Yes"><strong>Yes&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="See_a_light" value="Uncertain">Uncertain<br>&nbsp;&nbsp;&nbsp; If yes or uncertain, describe.<br><textarea cols="80" name="Describe_light" rows="5"></textarea><br> <font color="#FF0000"><br> 17.&nbsp; Did you see or feel surrounded by a brilliant light?</font><br> </strong><b> <input type="radio" name="Did_you_see_or_feel_surrounded_by_a_brilliant_light" value="Light clearly of mystical or other-worldly origin" checked>Light clearly of mystical or other-worldly origin<br> <input type="radio" name="Did_you_see_or_feel_surrounded_by_a_brilliant_light" value="Unusually bright light">Unusually bright light<br> <input type="radio" name="Did_you_see_or_feel_surrounded_by_a_brilliant_light" value="Neither">Neither</b></font></p> <p><font face="Arial"><font color="#FF0000"><strong>18.&nbsp; </strong></font> <b> <font color="#FF0000">Did you meet or see any other beings?</font><br></b> <input name="See_other_beings" type="radio" value="No" checked><strong>No &nbsp;&nbsp;&nbsp; </strong><input name="See_other_beings" type="radio" value="Yes"><strong>Yes&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="See_other_beings" value="Uncertain">Uncertain<br>&nbsp;&nbsp;&nbsp; </strong><b>If yes or uncertain, describe. Where were they? Did you know them? What was communicated? <br><textarea cols="80" name="Describe_other_beings" rows="5"></textarea><br> <font color="#FF0000"><br> 19.&nbsp; Did you seem to encounter a mystical being or presence?</font><br> <input type="radio" name="Did_you_seem_to_encounter_a_mystical_being_or_presence" value="Definite being, or voice clearly of mystical or other-worldly origin" checked>Definite being, or voice clearly of mystical or other-worldly origin<br> <input type="radio" name="Did_you_seem_to_encounter_a_mystical_being_or_presence" value="Unidentifiable voice">Unidentifiable voice<br> <input type="radio" name="Did_you_seem_to_encounter_a_mystical_being_or_presence" value="Neither">Neither<br> <br> <font color="#FF0000">20.&nbsp; Did you see deceased spirits or religious figures?</font><br> <input type="radio" name="Did_you_see_deceased_spirits_or_religious_figures" value="Saw them" checked>Saw them<br> <input type="radio" name="Did_you_see_deceased_spirits_or_religious_figures" value="Sensed their presence">Sensed their presence<br> <input type="radio" name="Did_you_see_deceased_spirits_or_religious_figures" value="Neither">Neither</b></font></p> <p><font face="Arial"><font color="#FF0000"><strong>21.&nbsp; </strong> </font><b><font color="#FF0000">Did you experience a review of past events in your life?</font> <br></b> <input name="Review_past_life" type="radio" value="No" checked><strong>No &nbsp;&nbsp;&nbsp; </strong><input name="Review_past_life" type="radio" value="Yes"><strong>Yes&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="Review_past_life" value="Uncertain">Uncertain<br>&nbsp;&nbsp;&nbsp; </strong><b>Describe in detail.&nbsp; Did you learn anything you did not previously know?&nbsp; Did you learn anything that helped you live your life after the experience?<br><textarea cols="80" name="Describe_life_review" rows="5"></textarea><br> <font color="#FF0000"><br> 22.&nbsp; Did scenes from your past come back to you?</font><br> <input type="radio" name="Did_scenes_from_your_past_come_back_to_you" value="Past flashed before me, out of my control" checked>Past flashed before me, out of my control<br> <input type="radio" name="Did_scenes_from_your_past_come_back_to_you" value="Remembered many past events">Remembered many past events<br> <input type="radio" name="Did_scenes_from_your_past_come_back_to_you" value="Neither">Neither</b></font></p> <p><font face="Arial"><font color="#FF0000"><strong>23.&nbsp; </strong></font> <b> <font color="#FF0000">Did you observe or hear anything regarding people or events during your experience that could be verified later?</font><br></b> <input name="See_things_later_verified" type="radio" value="No" checked><strong>No &nbsp;&nbsp;&nbsp; </strong><input name="See_things_later_verified" type="radio" value="Yes"><strong>Yes&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="See_things_later_verified" value="Uncertain">Uncertain<br>&nbsp;&nbsp;&nbsp; If yes or uncertain, describe.&nbsp; </strong><b>How did you verify this?<br><textarea cols="80" name="Describe_see_things_later_verified" rows="5"></textarea></b></font></p> <p><font face="Arial"><font color="#FF0000"><strong>24.&nbsp; </strong></font> <b> <font color="#FF0000">Did you see or visit any beautiful or otherwise distinctive locations, levels or dimensions?</font><br></b> <input name="See_or_visit_special_locations" type="radio" value="No" checked><strong>No &nbsp;&nbsp;&nbsp; </strong><input name="See_or_visit_special_locations" type="radio" value="Yes"><strong>Yes&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="See_or_visit_special_locations" value="Uncertain">Uncertain<br>&nbsp;&nbsp;&nbsp; </strong><b>If yes or uncertain, describe.<br><textarea cols="80" name="Describe_see_or_visit_special_locations" rows="5"></textarea><br> <font color="#FF0000"><br> 25.&nbsp; Did you seem to enter some other, unearthly world?</font><br> <input type="radio" name="Did_you_seem_to_enter_some_other_unearthly_world" value="Clearly mystical or unearthly realm" checked>Clearly mystical or unearthly realm<br> <input type="radio" name="Did_you_seem_to_enter_some_other_unearthly_world" value="Unfamiliar, strange place">Unfamiliar, strange place<br> <input type="radio" name="Did_you_seem_to_enter_some_other_unearthly_world" value="Neither">Neither</b></font></p> <p><font color="#FF0000"><strong><font face="Arial">26</font></strong></font><font face="Arial"><font color="#FF0000"><strong>.&nbsp; </strong> </font><b><font color="#FF0000">Did you have any sense of altered space or time?</font><br></b> <input name="Altered_space_or_time" type="radio" value="No" checked><strong>No &nbsp;&nbsp;&nbsp; </strong><input name="Altered_space_or_time" type="radio" value="Yes"><strong>Yes&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="Altered_space_or_time" value="Uncertain">Uncertain<br>&nbsp;&nbsp;&nbsp; If yes or uncertain, describe.<br><textarea cols="80" name="Describe_altered_space_or_time" rows="5"></textarea><br> <font color="#FF0000"><br> 27.&nbsp; Did time seem to speed up?</font><br> </strong><b> <input type="radio" name="Did_time_seem_to_speed_up" value="Everything seemed to be happening all at once" checked>Everything seemed to be happening all at once<br> <input type="radio" name="Did_time_seem_to_speed_up" value="Time seemed to go faster than usual">Time seemed to go faster than usual<br> <input type="radio" name="Did_time_seem_to_speed_up" value="Neither">Neither</b></font></p> <p><font color="#FF0000"><strong><font face="Arial">28</font></strong></font><font face="Arial"><font color="#FF0000"><strong>.&nbsp; </strong> </font><b><font color="#FF0000">Did you have a sense of knowing special knowledge, universal order and/or purpose?</font><br></b> <input name="Universal_order_or_purpose" type="radio" value="No" checked><strong>No &nbsp;&nbsp;&nbsp; </strong><input name="Universal_order_or_purpose" type="radio" value="Yes"><strong>Yes&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="Universal_order_or_purpose" value="Uncertain">Uncertain<br>&nbsp;&nbsp;&nbsp; </strong><b>If yes or uncertain, discuss and share what you came to know.<br><textarea cols="80" name="Describe_universal_order_or_purpose" rows="5"></textarea><br> <font color="#FF0000"><br> 29.&nbsp; Did you feel a sense of harmony or unity with the universe?</font></b><strong><br> </strong><b> <input type="radio" name="Did_you_feel_a_sense_of_harmony_or_unity_with_the_universe" value="United, one with the world" checked>United, one with the world<br> <input type="radio" name="Did_you_feel_a_sense_of_harmony_or_unity_with_the_universe" value="No longer in conflict with nature">No longer in conflict with nature<br> <input type="radio" name="Did_you_feel_a_sense_of_harmony_or_unity_with_the_universe" value="Neither">Neither<br> <br> <font color="#FF0000">30.&nbsp; Did you suddenly seem to understand everything?</font></b><strong><br> </strong><b> <input type="radio" name="Did_you_suddenly_seem_to_understand_everything" value="About the universe" checked>About the universe<br> <input type="radio" name="Did_you_suddenly_seem_to_understand_everything" value="About myself or others">About myself or others<br> <input type="radio" name="Did_you_suddenly_seem_to_understand_everything" value="Neither">Neither<br> <br> <font color="#FF0000">31.&nbsp; Did you seem to be aware of things going on elsewhere, as if by ESP?</font></b><strong><br> </strong><b> <input type="radio" name="Did_you_seem_to_be_aware_of_things_going_on_elsewhere" value="Yes, and facts later corroborated" checked>Yes, and facts later corroborated<br> <input type="radio" name="Did_you_seem_to_be_aware_of_things_going_on_elsewhere" value="Yes, but facts not yet corroborated">Yes, but facts not yet corroborated<br> <input type="radio" name="Did_you_seem_to_be_aware_of_things_going_on_elsewhere" value="Neither">Neither</b></font></p> <p><font color="#FF0000"><strong><font face="Arial">32</font></strong></font><font face="Arial"><font color="#FF0000"><strong>.&nbsp; </strong> </font><b><font color="#FF0000">Did you reach a boundary or limiting physical structure?</font><br></b> <input name="Boundary_or_limiting_structure" type="radio" value="No" checked><strong>No &nbsp;&nbsp;&nbsp; </strong><input name="Boundary_or_limiting_structure" type="radio" value="Yes"><strong>Yes&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="Boundary_or_limiting_structure" value="Uncertain">Uncertain<br>&nbsp;&nbsp;&nbsp; </strong><b>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?<br><textarea cols="80" name="Describe_boundary_or_limiting_structure" rows="5"></textarea><br> <font color="#FF0000"><br> 33.&nbsp; Did you come to a border or point of no return?</font></b><strong><br> </strong><b> <input type="radio" name="Did_you_come_to_a_border_or_point_of_no_return" value="A barrier I was not permitted to cross; or &quot;sent back&quot; to life involuntarily" checked>A barrier I was not permitted to cross; or &quot;sent back&quot; to life involuntarily<br> <input type="radio" name="Did_you_come_to_a_border_or_point_of_no_return" value="A conscious decision to &quot;return&quot; to life">A conscious decision to &quot;return&quot; to life<br> <input type="radio" name="Did_you_come_to_a_border_or_point_of_no_return" value="Neither">Neither</b></font></p> <p><font color="#FF0000"><strong><font face="Arial">34</font></strong></font><font face="Arial"><font color="#FF0000"><strong>.&nbsp; </strong> </font><b><font color="#FF0000">Did you become aware of future events?</font><br></b> <input name="Aware_future_life_events" type="radio" value="No" checked><strong>No &nbsp;&nbsp;&nbsp; </strong><input name="Aware_future_life_events" type="radio" value="Yes"><strong>Yes&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="Aware_future_life_events" value="Uncertain">Uncertain<br></strong><b>&nbsp;&nbsp; If yes or uncertain, describe.&nbsp; Based on your life following the experience, how accurate was this awareness?<br><textarea cols="80" name="Describe_aware_future_life_events" rows="5"></textarea><br> <font color="#FF0000"><br> 35.&nbsp; Did scenes from the future come to you?</font></b><strong><br> </strong><b> <input type="radio" name="Did_scenes_from_the_future_come_to_you" value="From the world's future" checked>From the world's future<br> <input type="radio" name="Did_scenes_from_the_future_come_to_you" value="From personal future">From personal future<br> <input type="radio" name="Did_scenes_from_the_future_come_to_you" value="Neither">Neither</b></font></p> <p><font color="#FF0000"><strong><font face="Arial">36</font></strong></font><font face="Arial"><font color="#FF0000"><strong>.&nbsp; </strong> </font><b><font color="#FF0000">Did you have any psychic, paranormal or other special gifts following the experience you did not have prior to the experience?</font><br></b> <input name="Psychic_or_paranormal_gifts" type="radio" value="No" checked><strong>No &nbsp;&nbsp;&nbsp; </strong><input name="Psychic_or_paranormal_gifts" type="radio" value="Yes"><strong>Yes&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="Psychic_or_paranormal_gifts" value="Uncertain">Uncertain<br></strong><b>&nbsp;&nbsp; If yes or uncertain, describe.<br><textarea cols="80" name="Describe_psychic_or_paranormal_gifts" rows="5"></textarea></b></font></p> <p><strong><font face="Arial" color="#FF0000">37</font></strong><font face="Arial"><font color="#FF0000"><strong>.&nbsp; </strong> </font><b><font color="#FF0000">Have you shared this experience with others?</font> <br></b> <input name="Shared_experience_with_others" type="radio" value="No" checked><strong>No &nbsp;&nbsp;&nbsp; </strong><input name="Shared_experience_with_others" type="radio" value="Yes"><strong>Yes&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="Shared_experience_with_others" value="Uncertain">Uncertain<br>&nbsp;&nbsp;&nbsp; </strong><b>If yes, How long was it between your experience and the time you first shared it with others?&nbsp; What were their reactions? Were they influenced in any way by your experience? How?<br><textarea cols="80" name="Describe_shared_experience_with_others" rows="5"></textarea></b></font></p> <p><b><span style="font-size: 12.0pt; font-family: Arial"> <font color="#FF0000">38.&nbsp; Did you have any knowledge of near death experience (NDE) prior to your experience?</font><br> </span></b><font face="Arial"> &nbsp;<input name="Did_you_have_any_knowledge_of_NDE_prior" type="radio" value="No" checked><strong>No &nbsp;&nbsp;&nbsp; </strong> <input name="Did_you_have_any_knowledge_of_NDE_prior" type="radio" value="Yes"><strong>Yes&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="Did_you_have_any_knowledge_of_NDE_prior" value="Uncertain">Uncertain<br> &nbsp;&nbsp;&nbsp; </strong></font><b> <span style="font-size: 12.0pt; font-family: Arial">If yes or uncertain, please explain.&nbsp; What was the source of your knowledge about NDE prior to the experience, and did it affect your experience in any way?</span></b><font face="Arial"><strong><br> </strong><b> <textarea cols="80" name="Describe_prior_NDE_knowledge" rows="5"></textarea></b></font><b><span style="font-size: 12.0pt; font-family: Arial"><font color="#FF0000"><br> <br> </font>39.&nbsp; Were there one or several parts of the experience especially meaningful or significant to you?&nbsp; Please explain.</span><span style="font-size: 12.0pt; font-family: Arial; color: navy"><br> </span></b><font face="Arial"><b> <textarea cols="80" name="Parts_of_the_experience_that_were_especially_meaningful" rows="5"></textarea></b></font><b><font color="#FF0000"><span style="font-size: 12.0pt; font-family: Arial"><br> <br> 40.&nbsp; How did you view the reality of your experience shortly (days to weeks) after it happened (choose the best response):</span></font><span style="font-size: 12.0pt; font-family: Arial; color: navy"><br> &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<input type="radio" name="Reality_of_your_experience_shortly_after" value="Experience was definitely real" checked>Experience was </span><span style="font-size: 12.0pt; font-family: Arial; color: blue"> definitely real</span><span style="font-size: 12.0pt; font-family: Arial; color: navy"><br> &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="Reality_of_your_experience_shortly_after" value="Experience was probably real">Experience was </span><span style="font-size: 12.0pt; font-family: Arial; color: blue"> probably real</span><span style="font-size: 12.0pt; font-family: Arial; color: navy"><br> &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="Reality_of_your_experience_shortly_after" value="Experience was probably not real">Experience was </span><span style="font-size: 12.0pt; font-family: Arial; color: blue"> probably not real</span><span style="font-size: 12.0pt; font-family: Arial; color: navy"><br> &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="Reality_of_your_experience_shortly_after" value="Experience was definitely not real">Experience was </span><span style="font-size: 12.0pt; font-family: Arial; color: blue"> definitely not real<br> <br> &nbsp;&nbsp;&nbsp; </span><span style="font-size: 12.0pt; font-family: Arial"> Please explain how you viewed the reality of your experience, and why, shortly (days to weeks) after it happened.</span><span style="font-size: 12.0pt; font-family: Arial; color: blue"><br> </span></b><font face="Arial"><b> <textarea cols="80" name="Explain_reality_of_experience_early_on" rows="5"></textarea></b></font><b><span style="font-size: 12.0pt; font-family: Arial; color: blue"><br> </span><font color="#FF0000"><span style="font-family: Arial"><br> 41</span><span style="font-size: 12.0pt; font-family: Arial">.&nbsp; </span></font> <span style="font-size: 12.0pt; font-family: Arial; color: #FF0000">How do you currently</span><font color="#FF0000"><span style="font-size: 12.0pt; font-family: Arial"> view the reality of your experience (choose the best response):</span></font><span style="font-size: 12.0pt; font-family: Arial; color: navy"><br> &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<input type="radio" name="Reality_of_your_experience_currently" value="Experience was definitely real" checked>Experience was </span><span style="font-size: 12.0pt; font-family: Arial; color: blue"> definitely real</span><span style="font-size: 12.0pt; font-family: Arial; color: navy"><br> &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="Reality_of_your_experience_currently" value="Experience was probably real">Experience was </span><span style="font-size: 12.0pt; font-family: Arial; color: blue"> probably real</span><span style="font-size: 12.0pt; font-family: Arial; color: navy"><br> &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="Reality_of_your_experience_currently" value="Experience was probably not real">Experience was </span><span style="font-size: 12.0pt; font-family: Arial; color: blue"> probably not real</span><span style="font-size: 12.0pt; font-family: Arial; color: navy"><br> &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="Reality_of_your_experience_currently" value="Experience was definitely not real">Experience was </span><span style="font-size: 12.0pt; font-family: Arial; color: blue"> definitely not real<br> <br> &nbsp;&nbsp;&nbsp; </span><span style="font-size: 12.0pt; font-family: Arial"> Please explain how you view the reality of your experience, and why, currently.</span><span style="font-size: 12.0pt; font-family: Arial; color: blue"><br> </span></b><font face="Arial"><b> <textarea cols="80" name="Explain_reality_of_experience_currently" rows="5"></textarea></b></font><b><span style="font-size: 12.0pt; font-family: Arial; color: navy"><br> </span><strong><font color="#FF0000"> <span style="font-size: 12.0pt; font-family: Arial"><br> 42</span></font></strong></b><font face="Arial"><strong><font color="#FF0000">.&nbsp; </font> </strong></font> <strong><span style="font-size: 12.0pt; font-family: Arial; color: red">Have your relationships&nbsp;changed specifically as a result of your experience?</span></strong><font face="Arial"><strong><br> </strong> &nbsp;<input name="Have_your_relationships_changed" type="radio" value="No" checked><strong>No &nbsp;&nbsp;&nbsp; </strong> <input name="Have_your_relationships_changed" type="radio" value="Yes"><strong>Yes&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="Have_your_relationships_changed" value="Uncertain">Uncertain<br> &nbsp;&nbsp;&nbsp; </strong></font><strong> <span style="font-size: 12.0pt; font-family: Arial">If yes or uncertain, please describe:<br> </span></strong><font face="Arial"><strong> <textarea cols="80" name="Explain_changed_relations" rows="5"></textarea><br> <font color="#FF0000"><br> 43.&nbsp; </font></strong></font><strong> <span style="font-size: 12.0pt; font-family: Arial; color: red">Have your religious beliefs/practices&nbsp;changed specifically as a result of your experience?</span></strong><font face="Arial"><strong><br> </strong> &nbsp;<input name="Have_your_religious_beliefs_changed" type="radio" value="No" checked><strong>No &nbsp;&nbsp;&nbsp; </strong> <input name="Have_your_religious_beliefs_changed" type="radio" value="Yes"><strong>Yes&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="Have_your_religious_beliefs_changed" value="Uncertain">Uncertain<br> &nbsp;&nbsp;&nbsp; </strong></font><strong> <span style="font-size: 12.0pt; font-family: Arial">If yes or uncertain, please describe:<br> </span></strong><font face="Arial"><strong> <textarea cols="80" name="Explain_changed_religious_beliefs_practices" rows="5"></textarea><br> <font color="#FF0000"><br> 44.&nbsp; </font></strong><b><font color="#FF0000">Following the experience, have you had any other events in your life, medications or substances which reproduced any part of the experience?</font> <br></b> <input name="Substances_later_reproduce_NDE_experience" type="radio" value="No" checked><strong>No &nbsp;&nbsp;&nbsp; </strong><input name="Substances_later_reproduce_NDE_experience" type="radio" value="Yes"><strong>Yes&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="Substances_later_reproduce_NDE_experience" value="Uncertain">Uncertain<br>&nbsp;&nbsp;&nbsp; If yes or uncertain, describe.<br><textarea cols="80" name="Describe_substances_later_reproduce_NDE_experience" rows="5"></textarea></strong></font><font color="#FF0000"><strong><font face="Arial"><br> </font></strong></font><font face="Arial"><strong><br> 45.&nbsp; </strong><b> Is there anything else you would like to add concerning the experience?<br><textarea cols="80" name="Anything_else_concerning_NDE" rows="5"></textarea></b></font><font color="#FF0000"><strong><font face="Arial"><br> <br> 46</font></strong></font><font face="Arial"><font color="#FF0000"><strong>.&nbsp; </strong> </font><b><font color="#FF0000">Did the questions asked and information you provided so far accurately and comprehensively describe your experience?</font><br></b> <input name="Questions_and_info_provided_describe_NDE" type="radio" value="No" checked><strong>No &nbsp;&nbsp;&nbsp; </strong><input name="Questions_and_info_provided_describe_NDE" type="radio" value="Yes"><strong>Yes&nbsp;&nbsp;&nbsp;&nbsp; <input type="radio" name="Questions_and_info_provided_describe_NDE" value="Uncertain">Uncertain<br>&nbsp;&nbsp;&nbsp; Please explain.<br><textarea cols="80" name="Explain_questions_and_info_provided_describe_NDE" rows="5"></textarea></strong></font></p> <font face="Arial"><b> <p>47<span style="font-size: 12.0pt; font-family: Arial">.&nbsp; What could a national organization with an interest in near death experience (NDE) do that would be of most interest to you (check all that apply)?<br> <input type="checkbox" name="Organization_help_Nothing" value="Nothing">Nothing<br> <input type="checkbox" name="Organization_help_Local_meetings_NDE_plus" value="Local meetings regarding NDE and related experiences">Local meetings regarding NDE and related experiences<br> <input type="checkbox" name="Organization_help_Local_meetings" value="Local meetings regarding only NDE">Local meetings regarding only NDE<br> <input type="checkbox" name="Organization_help_NDEr_talks" value="In person presentation of NDE accounts by the individual who experienced the NDE">In person presentation of NDE accounts by the individual who experienced the NDE<br> <input type="checkbox" name="Organization_hep_Present_written_NDE" value="Present written NDE accounts">Present written NDE accounts<br> <input type="checkbox" name="Organization_help_Conferences" value="National-regional conferences about NDE">National/regional conferences about NDE<br> <input type="checkbox" name="Organization_help_Web_site" value="An Internet web site about NDE">An Internet web site about NDE<br> <input type="checkbox" name="Organization_help_Media_presentations" value="Media presentations about NDE (television, radio, magazine, newspaper) ">Media presentations about NDE (television, radio, magazine, newspaper) <br> <input type="checkbox" name="Organization_help_Newsletter" value="Publication of a newsletter about NDE">Publication of a newsletter about NDE<br> <input type="checkbox" name="Organization_help_Book_pamphlet" value="Publication of a book-pamphlet about NDE">Publication of a book/pamphlet about NDE<br> <input type="checkbox" name="Organization_help_Scientific_study" value="Scientific study of NDE">Scientific study of NDE<br> <input type="checkbox" name="Organization_help_Communication_other_NDErs" value="Facilitate communication between myself and others who had a NDE">Facilitate communication between myself and others who had a NDE<br> <input type="checkbox" name="Organization_help_Communication_others_interested_in_NDE" value="Facilitate communication between myself and others interested in NDE">Facilitate communication between myself and others interested in NDE<br> <input type="checkbox" name="Organization_help_Other" value="Other">Other suggestions/comments:<br> </span><strong> <textarea cols="80" name="Organization_help_Other_explain" rows="5"></textarea></strong></b><strong><br> <br> 48.</strong>&nbsp; <b>Please offer any suggestions you may have to improve this questionnaire.&nbsp; Are there any other questions we could ask to help you communicate your experience?<br><textarea cols="80" name="Suggestions_to_help_us_understand_NDE" rows="5"></textarea></b></font></p> <p><B><font color="#800080" face="Arial" style="font-size: 16pt">Page Validation Question: Make sure to type &quot;fox&quot; in question #1 at the top of the form or the form won't go through.</font></b></p> <p><font face="Arial"><strong><font color="#000080">&nbsp;&nbsp;&nbsp;</font><font color="#0000FF" size="5" face="Arial"><i>Thanks!!!</i></font></strong></font></p> <div align="left"> <font face="Arial"><input name="B1" type="submit" value="Submit"> <img border="0" src="../images/busy.gif" width="32" height="32"> <font color="#ff0000" face="Arial"><strong><big><font size="5">Remember to Submit completed form!</font></big>&nbsp; </strong></font></font></div> <div align="left"> <font face="Arial"> <font color="#ff0000" face="Arial"><strong> <br><sup><big><big><br> Caution... Reset button will erase ALL data entered!&nbsp; </big></big></sup></strong></font> <input name="B2" type="reset" value="Reset"></font></div></form> <h5><font color="#008000"><i>Special thanks</i></font> to Dr. Bruce Greyson and Dr. Ken Ring who graciously allowed questions they developed to be used as part of this project.<br> Some questions from Bruce Greyson, &quot;The Near-Death Experience Scale: Construction, Reliability, and Validity,&quot; <i>Journal of Nervous and Mental Disease</i>, 171:369-375.&nbsp; Copyright 1983, The Williams and Wilkins Co.<br> <br> Last revised: <!--webbot bot="TimeStamp" S-Type="EDITED" S-Format="%B %d, %Y" startspan -->July 17, 2009<!--webbot bot="TimeStamp" i-checksum="14560" endspan --></h5> <font FACE="Arial"> <p align="center"><strong> <font color="#993399"><br> </font></strong><b> <img border="0" src="../images/blultbar.gif" width="575" height="10"> </b> <strong> <font color="#993399"> <br> </font></strong><b>&nbsp;</b></p> <p align="center"> <font color="#0033CC" face="Arial"> <a name="Copyright1999 by Dr. Jeffrey P. Long">Copyright<img border="0" src="../images/copyright_chromeshimmer_sm_wht_24508.gif" id="copyright_chromeshimmer_sm_wht_24508_gif" name="copyright_chromeshimmer_sm_wht_24508_gif" width="25" height="25">1999 by Dr. Jeff &amp; Jody Long</a> </font> </p> </font> <p align="center"><font color="#0000FF"><br> </font><font color="#800080" face="Arial">e-mail:</font><font color="#0033CC" face="Arial"> <a href="mailto:nderf@nderf.org">nderf@nderf.org</a>&nbsp; </font> <font color="#800080" face="Arial">Webmaster:&nbsp; Jody A. Long<br> <br> </font><font face="Arial"><b><font size="2" color="#000080">Jody A. Long Professional Websites</font></b><font size="2"><font color="#000080"><br> </font><font color="#800080">Jody A. Long's Family Law web site</font>: <a href="http://www.attyfamilylaw.com">www.attyfamilylaw.com</a>; <font color="#800080">Jewelry by Jody</font> <a href="http://www.jewelrybyjody.com">www.jewelrybyjody.com</a><br> &nbsp;</font></font></p> <p align="center"><font color="#0000FF"> <!--webbot bot="HitCounter" i-image="2" i-digits="0" PREVIEW="&lt;strong&gt;[Hit Counter]&lt;/strong&gt;" u-custom i-resetvalue="0" startspan --><img src="../_vti_bin/fpcount.exe/?Page=Polish/Share%20NDE%20Polish.htm|Image=2" alt="Hit Counter"><!--webbot bot="HitCounter" i-checksum="16470" endspan --> (From 10/20/02)</font></p>