ADCRF Questionnaire | Experience Research Foundation

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Scroll down to find the ADCRF Questionnaire form (be sure to read Overview and Form Instructions)

Overview:

Your experiences may be submitted to us (in order of preference):

1. Preferred: via the questionnaire form below.

2. Via e-mail. E-mailing your account is acceptable, but for research it is much better if we can tabulate the results from your completion of the Questionnaire form below. Thanks!

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

Completing this questionnaire will take approximately 25 minutes or longer depending on how much you wish to write. While you work, your answers are kept privately on your own device, so if you are interrupted you can come back later on the same device and browser and continue where you left off. (On a shared or public computer, you can turn this off at the top of the form.)

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. We understand that some questions 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.

3. The questions that are in red require responses. This is very important… you will not be able to submit the questionnaire until all questions in red have been answered! If you skip a red question, the form will point it out when you press "Next" or "Submit," so you can answer it before going on. Please fill out all questions to the best of your ability. If you skip a Yes/No question, it will be recorded as "No Response."

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

5. After you press the "Submit" button upon completing the questionnaire, a review of your responses to the questions will be shown. If you press edit, you go back to the form. If you press confirm, then you have your answers to the question and you can print or save them for your own records. You will also get information about ADCRF/NDERF/OBERF, how privacy works, and other general information. So please put an e-mail address that allows e-mails to come to you or add nderf@nderf.org and jody@nderf.org to your approved senders list. If you do not receive the general information, check your spam or please e-mail me with a secondary e-mail address to send this to you.

6. CONSENT: I wish the account of my experience to be placed in the ADCRF archives. I understand it may be read by researchers, students, or others approved by NDERF for use of the archives. [NO IDENTIFYING PERSONAL INFORMATION will be given to anyone but Jeff or me. That means that names, e-mails, addresses, and telephone numbers are strictly confidential.] My account may be excerpted or used in full, or data may be drawn from it in conjunction with an Experience Research Foundation approved study or project, including but not limited to lectures or educational programs, or part of a published article, or in a book. [If you do not wish your experience to be used like this, then please let us know and tell us what use you would prefer. This can be done by e-mail or by check mark in the publishing consent box below. Your comfort in sharing with NDERF/OBERF/ADCRF is of the utmost importance to us. ] THANKS!!!

Check that the 'Caps Lock' button on your keyboard is off.

Name

Please answer this question.

Postal Address

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Telephone

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E-mail

Please enter your e-mail address.

Gender:

Male Female

Please answer this question.

Contact restrictions (if any) & instructions:

No contact whatsoever A researcher approved by OBERF/ADCRF/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.

Please answer this question.

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

Please answer this question.

*NOTE: Please make sure your web browser and e-mail service do not place nderf@nderf.org or jody@nderf.org in spam, delete or reject status - otherwise we can't contact you. Also, we never send attachments. Do NOT open attachments from either of these e-mails because they contain viruses and are spoofing (not from us)!

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

1. How to publish:

Total Permission

Under no circumstances

On Website

Ask Permission

2. Where to publish:

Anonymously (without my name)

With my E-Mail address

First Name and First Initial of Last Name

With my address

Have you had multiple experiences?

No Yes Uncertain No Response

Please answer this question.

If yes or uncertain, how many experiences? If yes, and only several experiences, please consider completing this form for each experience. If more than several, or if you prefer, please complete this form regarding your most meaningful or significant experience.

Please answer this question.

How many deceased or other beings were present in the experience?

Please answer this question.

Only if multiple deceased or other beings, and if possible, please answer the following questions in this format: On each line, identify the deceased, comma after their name, then respond to the question. For example the next question could be responded as:
Mary, Mother
Joe, Uncle (Father's side)
Sue, Close friend

The following are questions about the deceased. If you are not sure of the exact answer, but have a reasonably approximate answer, please give the approximate answer. If you have no idea of the answer, please enter "unknown". If you do not wish to respond to the question, please enter "no response" or "NR".

Name of the deceased:

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Relation of deceased to you (i.e. father, son, friend, neighbor, etc.):

Please answer this question.

Do you have any comments about the relationship you had with the deceased?

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What was the occupation of the deceased?

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What was the cause of death of the deceased?

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What was the age of the deceased when they passed over?

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Today's Date

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Date of experience:

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Time between the time of the death of the deceased person and your experience:

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Was the date of the experience significant in any way (for example: anniversary, holiday, birthday, critical time in life, etc.):

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Your age at time of experience:

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Age now:

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

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Details of location of experience and your activity at time of experience (for example: sleeping, in reading in bed in bedroom, at funeral of deceased, driving a car to work, cooking in kitchen, etc.):

Please answer this question.

Degree of bereavement for deceased immediately prior to the experience (choose best response):

No sadness and/or grief feelings Slight sadness and/or grief feelings Moderate sadness and/or grief feelings Moderately severe sadness and/or grief feelings Severe sadness and/or grief feelings No Response

Please answer this question.

Degree of alertness immediately prior to experience (choose best response):

Fully alert Slightly drowsy Very drowsy Asleep No Response

Please answer this question.

Was the experience witnessed or experienced by others?

No Yes Uncertain No Response

Please answer this question.

If Yes or Uncertain, describe:

Please answer this question.

Your current principal occupation:

Please answer this question.

Your main interests and hobbies:

Please answer this question.

Your religious background at time of experience (Faith/Denomination, or 'None'):

Conservative/fundamentalist Moderate Liberal None Uncertain No Response

Please answer this question.

Describe below if more explanation is needed.

Please answer this question.

Your religious background currently (Faith/Denomination, or 'None'):

Conservative/fundamentalist Moderate Liberal None Uncertain No Response

Please answer this question.

Describe below if more explanation is needed.

Please answer this question.

Race (check as many as apply):

Caucasian

Black

Hispanic

Asian

Native American

Other (briefly specify):

Please answer this question.

Country of birth:

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After your experience, did you consider the contents of your experience:

Wonderful Frightening Mixed

Please answer this question.

Highest level of EDUCATION. Please click on the drop box to display the choices. Carefully review all the choices in the list, then select the one best response). Non-USA respondents please make a best guess of the response most equivalent to your education level:

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1. Were there any associated medications or substances with the potential to affect the experience?

No Yes Uncertain No Response

Please answer this question.

If Yes or Uncertain, please explain:

Please answer this question.

2. Was the kind of experience difficult to express in words?

No Yes Uncertain No Response

Please answer this question.

If Yes or Uncertain, what was it about the experience that makes it hard to communicate?

Please answer this question.

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, text will automatically scroll at right end of box):

Please write an answer to this question.

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4. Did you ONLY sense an awareness or presence of the deceased without actually seeing, hearing, feeling or smelling them (if you saw, heard felt or smelled them, check 'No')?

No Yes Uncertain No Response

Please answer this question.

5. Did you hear the deceased or hear something associated with the deceased?

No Yes Uncertain No Response

Please answer this question.

Describe what you heard, how clearly you heard it and what was communicated:

Please answer this question.

Did the voice or sound seem to originate externally or outside of you, inside you, or did you not hear a voice or sound, but had a sense of knowing what was communicated? Please describe.

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If you heard a voice or sound, was it similar or dissimilar from the voice or sound the deceased made when they were alive?

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Is there any possibility what you heard was from any other source present in the surroundings at the time of your experience?

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Was there any possible impairment to your hearing at the time of the experience?

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6. Did you feel a touch or experience any physical contact from the deceased?

No Yes Uncertain No Response

Please answer this question.

Where and how were you touched?

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Was the touch familiar or unfamiliar? Describe.

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Was anything communicated by the touch? Describe.

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Is there any possibility what you felt was from any other source present in the surroundings at the time of your experience?

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7. Did you see the deceased?

No Yes Uncertain No Response

Please answer this question.

Describe the appearance of the deceased, and comment on any similarities and differences in how they appeared from their appearance when alive:

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How clearly did the deceased appear (i.e. solid, somewhat transparent, etc.):

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How much of the deceased did you see (i.e. all or part of the deceased):

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Did the deceased appear or not appear to be the age at which they died? Describe.

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How healthy did the deceased appear to be? Did they have any infirmities before they died which might have been apparent or not apparent? Describe.

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Is there any possibility what you saw was from any other source present in the surroundings at the time of your experience?

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8. Did you smell a distinct smell, scent, fragrance or odor associated with the deceased?

No Yes Uncertain No Response

Please answer this question.

What smell, scent, fragrance or odor did you smell? Describe.

Please answer this question.

Was the smell, scent, fragrance or odor familiar? Describe.

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Was anything communicated by the smell? Describe.

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Is there any possibility that the smell, scent, fragrance or odor was from any other source present in the surroundings at the time of your experience?

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9. How long did the experience last?

Please answer this question.

10. Was the beginning and end of the experience gradual or more sudden? Describe.

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11. Could you sense the emotions or mood of the deceased?

No Yes Uncertain No Response

Please answer this question.

If Yes or Uncertain, Describe.

Please answer this question.

12. Did the deceased give you information you did not previously know? Describe in detail. If you received any information whether true or not true, helpful or not helpful, please describe in detail.

Please answer this question.

13. Prior to the experience, did you believe in after death communication? (choose the best response, to the best of your recollection):

Absolutely Believed it probably could happen Believed it not likely to happen absolutely not No Response

Please answer this question.

14. Prior to the experience did you believe in the possibility of life after death (choose the best response, to the best of your recollection):

Absolutely Believed it probably could happen Believed it not likely to happen absolutely not No Response

Please answer this question.

15. Prior to the experience did you believe in the existence of God or a Supreme Being (choose the best response, to the best of your recollection):

Absolutely Believed God probably exists Believed God does not likely exist absolutely not No Response

Please answer this question.

16. Prior to the experience were you afraid of death (choose the best response, to the best of your recollection):

Very fearful Moderately fearful Slightly fearful Not fearful No Response

Please answer this question.

17. After your experience, do you believe in after death communication? (choose the best response, to the best of your recollection):

Absolutely Believed it probably could happen Believed it not likely to happen absolutely not No Response

Please answer this question.

18. After your experience do you believe in the possibility of life after death (choose the best response, to the best of your recollection):

Absolutely Believed it probably could happen Believed it not likely to happen absolutely not No Response

Please answer this question.

19. After your experience do you believe in the existence of God or a Supreme Being (choose the best response, to the best of your recollection):

Absolutely Believed God probably exists Believed God does not likely exist absolutely not No Response

Please answer this question.

20. After your experience are you afraid of death (choose the best response):

Very fearful Moderately fearful Slightly fearful Not fearful No Response

Please answer this question.

21. 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 No Response

Please answer this question.

Please explain why you view the reality of your experience as real or not real.

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21.5 Was the experience dream like in any way?

No Yes Uncertain No Response

Please answer this question.

If Yes or Uncertain, Describe.

Please answer this question.

22. What did you feel (while awake) immediately prior to your experience (check as many as apply):

Relaxed

Happy

Grieving

Sad

Suicidal

Angry

Confused

No particular emotion

No Response

23. Describe in detail your feelings/emotions during the experience:

Please answer this question.

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24. What emotions did you experience following your experience?

Please answer this question.

25. Was there any emotional healing in any way following the experience?

No Yes Uncertain No Response

Please answer this question.

If yes or uncertain, describe.

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26. What other attitudes and beliefs about your experience do you currently have (Check all that apply):

Sacred

Hallucination

Delusion

Life-changing

Fantasy

Dream

No particular attitude

Fear

Joy

Other belief

Please answer this question.

27. Did the experience give you any spiritual understandings such as life, death, afterlife, God, etc.?

No Yes Uncertain No Response

Please answer this question.

If Yes or Uncertain, please describe:

Please answer this question.

28. "Death Compacts" are when two or more living people promise among themselves that whoever dies first will try to contact the other(s). Have ever made such a compact?

No Yes Uncertain No Response

Please answer this question.

If yes or uncertain, what did you do and what was the result of the experimentation?

Please answer this question.

29. Did you observe or hear anything regarding people or events during your experience that could be verified later?

No Yes Uncertain No Response

Please answer this question.

If Yes or Uncertain, describe. How did you verify this?

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30. Did you experience a separation of consciousness from your body?

No Yes Uncertain No Response

Please answer this question.

If Yes or Uncertain, describe.

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31. Did you meet or see any other beings other than the deceased?

No Yes Uncertain No Response

Please answer this question.

If yes or uncertain, describe. Where were they? Did you know them? What was communicated?

Please answer this question.

32. Did you see a light?

No Yes Uncertain No Response

Please answer this question.

If yes or uncertain, describe.

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33. Did any part of your experience seem to occur in a place other than the location described above?

No Yes Uncertain No Response

Please answer this question.

If yes or uncertain, describe.

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34. Did you have any sense of altered space or time?

No Yes Uncertain No Response

Please answer this question.

If yes or uncertain, describe.

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35. Did you have a sense of knowing special knowledge, universal order and/or purpose?

No Yes Uncertain No Response

Please answer this question.

If Yes or Uncertain, discuss and share what you came to know.

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36. Did you become aware of future events?

No Yes Uncertain No Response

Please answer this question.

If Yes or Uncertain, describe. Based on your life following the experience, how accurate was this awareness?

Please answer this question.

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37. 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

Please answer this question.

If yes or uncertain, describe.

Please answer this question.

38. Did you have any changes of attitudes or beliefs following the experience?

No Yes Uncertain No Response

Please answer this question.

If yes or uncertain, describe.

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39. Has your life changed specifically as a result of your experience?

No Yes Uncertain No Response

Please answer this question.

If Yes or Uncertain, describe how. (For example: Has the experience affected your relationships? Daily life? Religious practices etc.? Career choices?)

Please answer this question.

40. Have you shared this experience with others?

No Yes Uncertain No Response

Please answer this question.

If Yes, What were their reactions? Were they influenced in any way by your experience? How?

Please answer this question.

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

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42. Have you shared this experience formally or informally with any other researcher or web site?

No Yes Uncertain No Response

Please answer this question.

If Yes or Uncertain, please describe: How?

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43. Is there anything else you would like to add regarding your experience?

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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 No Response

Please answer this question.

If yes or uncertain, describe.

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45. Did you ever in your life have a near-death experience, out of body experience or other spiritual event?

No Yes Uncertain No Response

Please answer this question.

If Yes or Uncertain, describe:

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46. Did the questions asked and information you provided accurately and comprehensively describe your experience?

No Yes Uncertain No Response

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Explain.

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47. 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?

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Thanks!!!