Near death experience accounts may be submitted to us (in order of preference):

            1.    Via the form on the NDERF web site (below).

            2.    Via e-mail (see e-mail links at the bottom of each page).  

 While we greatly appreciate experience contributions, we regret there can be no monetary compensation to contributors. Confidentiality of all communications will be strictly maintained to the extent desired by the contributor.

We have a series of questions, and will also record aspects of the experience not covered by our questions. We expect these will be modified over time to help us more accurately understand NDE and related experiences.  Completing these questions will take approximately 40 minutes.

Your willingness to share your experience is vital to the success of this project. We express our heartfelt thanks in advance to those willing to share!

Form Instructions:

1.    Please fill out the form below as completely and accurately as you can.  Please carefully consider your responses prior to making them.

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". 
            We understand there are a number of questions that may ask the same concept in several different ways.  This survey is a combination of the most validated and respected questions regarding near death experiences from the top researchers in the world.  ALL your responses, even to similarly worded questions, are meaningful, and extremely important for our understanding.

3.   The questions that are in red require responses.  This is very important… you will not be able to send any information at all until all questions in red have been answered!  If you did not respond to one or several red 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.  All questions with radio option buttons ("") require a response.  Please fill out all text box ("") questions to the best of your ability, but be aware that the only text boxes where response is absolutely required have red lettering immediately above the box.

4.    Please do not forget to press the "Submit" button at the end or the information will be lost! 

5.    After you press the submit button upon completing the form, 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.

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.  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 or identifying information will not be used unless I give express permission to do so.  THANKS!!!

7.  To prevent spammers and other inappropriate uses of this form, we have a special request:
     Please type "fox" (case sensitive) in the first question immediately below, labeled as a Page Validation Question:

=================================================================================================================

1.  Page Validation Question: Type "fox" in the box:  

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):

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:
 Female     Male

Condition around the time of experience (select best choice):

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

Did your experience include (check all that apply):

Your current principal occupation:                      

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:
 

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:
 Wonderful    Frightening     Mixed

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):
  1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade High School + 1 year High School + 2 years High School + Three Years College Graduate (4 years) or Equivalent College Graduate (4 years) + 1 year College Graduate (4 Years) + 2 Years (Masters Degree) College Graduate (4 Years) + 3 Years College Graduate (4 Years) + 4 Years (Doctorate) College (4 Years) + More Than 4 Years Post College

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

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


3.  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):
 

4.  At what time during the experience were you at your highest level of consciousness and alertness?
 

5.  How did your highest level of consciousness and alertness during the experience compare to your normal every day consciousness and alertness?
More consciousness and alertness than normal
Normal consciousness and alertness
Less consciousness and alertness than normal

    If your highest level of consciousness and alertness during the experience was different from your normal every day consciousness and alertness, please explain:


6.  Were your thoughts speeded up?
Incredibly fast
Faster than usual
Neither

7.  Were your senses more vivid than usual?
Incredibly more so
More so than usual
Neither

8.  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.)?
 No     Yes     Uncertain
    If yes or uncertain, describe.


9.  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.)?
 No     Yes     Uncertain
    If yes or uncertain, describe.  

10.  Did you experience a separation of your consciousness from your body?
No     Yes     Uncertain

11.  Did you feel separated from your physical body?
Clearly left the body and existed outside it
Lost awareness of the body
Neither

12.  What emotions did you feel during the experience?


13.  Did you have a feeling of peace or pleasantness?
Incredible peace or pleasantness
Relief or calmness
Neither

14.  Did you have a feeling of joy?
Incredible joy
Happiness
Neither

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

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


17.  Did you see or feel surrounded by a brilliant light?
Light clearly of mystical or other-worldly origin
Unusually bright light
Neither

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


19.  Did you seem to encounter a mystical being or presence?
Definite being, or voice clearly of mystical or other-worldly origin
Unidentifiable voice
Neither

20.  Did you see deceased spirits or religious figures?
Saw them
Sensed their presence
Neither

21.  Did you experience a review of past events in your life?
No     Yes     Uncertain
    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?


22.  Did scenes from your past come back to you?
Past flashed before me, out of my control
Remembered many past events
Neither

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

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


25.  Did you seem to enter some other, unearthly world?
Clearly mystical or unearthly realm
Unfamiliar, strange place
Neither

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


27.  Did time seem to speed up?
Everything seemed to be happening all at once
Time seemed to go faster than usual
Neither

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


29.  Did you feel a sense of harmony or unity with the universe?
United, one with the world
No longer in conflict with nature
Neither

30.  Did you suddenly seem to understand everything?
About the universe
About myself or others
Neither

31.  Did you seem to be aware of things going on elsewhere, as if by ESP?
Yes, and facts later corroborated
Yes, but facts not yet corroborated
Neither

32.  Did you reach a boundary or limiting physical structure?
No     Yes     Uncertain
    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?


33.  Did you come to a border or point of no return?
A barrier I was not permitted to cross; or "sent back" to life involuntarily
A conscious decision to "return" to life
Neither

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


35.  Did scenes from the future come to you?
From the world's future
From personal future
Neither

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

37.  Have you shared this experience with others?
No     Yes     Uncertain
    If yes, How long was it between your experience and the time you first shared it with others?  What were their reactions? Were they influenced in any way by your experience? How?

38.  Did you have any knowledge of near death experience (NDE) prior to your experience?
 No     Yes     Uncertain
    If yes or uncertain, please explain.  What was the source of your knowledge about NDE prior to the experience, and did it affect your experience in any way?


39.  Were there one or several parts of the experience especially meaningful or significant to you?  Please explain.


40.  How did you view the reality of your experience shortly (days to weeks) after it happened (choose the best response):
        Experience was definitely real
        Experience was probably real
        Experience was probably not real
        Experience was definitely not real

    Please explain how you viewed the reality of your experience, and why, shortly (days to weeks) after it happened.


41.  How do you currently view the reality of your experience (choose the best response):
        Experience was definitely real
        Experience was probably real
        Experience was probably not real
        Experience was definitely not real

    Please explain how you view the reality of your experience, and why, currently.


42.  Have your relationships changed specifically as a result of your experience?
 No     Yes     Uncertain
    If yes or uncertain, please describe:


43.  Have your religious beliefs/practices changed specifically as a result of your experience?
 No     Yes     Uncertain
    If yes or uncertain, please describe:


44.  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
    If yes or uncertain, describe.


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


46.  Did the questions asked and information you provided so far accurately and comprehensively describe your experience?
No     Yes     Uncertain
    Please explain.

47.  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)?
Nothing
Local meetings regarding NDE and related experiences
Local meetings regarding only NDE
In person presentation of NDE accounts by the individual who experienced the NDE
Present written NDE accounts
National/regional conferences about NDE
An Internet web site about NDE
Media presentations about NDE (television, radio, magazine, newspaper)
Publication of a newsletter about NDE
Publication of a book/pamphlet about NDE
Scientific study of NDE
Facilitate communication between myself and others who had a NDE
Facilitate communication between myself and others interested in NDE
Other suggestions/comments:


48.  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?

Page Validation Question: Make sure to type "fox" in question #1 at the top of the form or the form won't go through.

   Thanks!!!

Special thanks to Dr. Bruce Greyson and Dr. Ken Ring who graciously allowed questions they developed to be used as part of this project.
Some questions from Bruce Greyson, "The Near-Death Experience Scale: Construction, Reliability, and Validity," Journal of Nervous and Mental Disease, 171:369-375.  Copyright 1983, The Williams and Wilkins Co.

Last revised: February 29, 2008

e-mail: nderf@nderf.org  Webmaster:  Jody A. Long, JD 

Jody A. Long, JD & Jeffrey Long, MD (of NDERF) Professional Websites
Jody A. Long's Family Law web site: www.attyfamilylaw.com; Jewelry by Jody www.jewelrybyjody.com
Dr. Jeffrey Long's Radiation Oncology (the use of radiation to treat cancer) web site: www.rooj.com

(From 10/20/02)