Building Global Understanding of Near-Death Experiences
Most fields below are required. Please fill in as much detail as you can
Name (required):
Address: (required) City or Town, State or Province, Zip or Postal Code: (required)
IANDS may publish my experience.... (Permission does not guarantee publication). Specify permission for each:
No, Under No Circumstances Yes, Anonymously Only Yes, with my Name Only Yes, with my Name and Address
1. Your condition during the experience:
2. Circumstances of the experience (check all that apply):
3. Your status of health after the experience: Excellent Good Fair Poor
4. Your status of health now: Excellent Good Fair Poor
5. At the time, did you consider the contents of your experience: Wonderful Frightening Mixed
6. Did your experience include (check all that apply):
7. Have you experienced changes in any of the following resulting from the experience (check as many as apply):
8. Have these changes been: Positive Disturbing Mixed
9. Has your life changed specifically as a result of your experience? Yes No
Describe these changes unless you plan to discuss them in your experience narrative below:
10. Over time, did your after effect: Increase Decrease Stay about the same
11. Your principal occupation:
12. Your main interests and hobbies:
13a. Your religious background: Faith/denomination (or 'None')
13b. Your religious background: Conservative/fundamentalist Moderate Liberal
14. Your sex: Female Male
15. Your race: (check as many as apply): Caucasian; Black; Hispanic; Asian; Native American Other (please specify):
16. Your country of birth:
17. Country(ies) of family origin:
Questions 18 through 27 relate only to NDEs that are combat-related, as specified in Question 2. They aren't shown unless you indicate in Question 2 that your experience was combat related (unless your browser doesn't support hiding them).
Skip to Question 28 if your experience was not combat-related.
Enter NA if a question doesn't apply to you (for example, if you were a non-combatant caught in combat).
18. What unit did you belong to?
19. Where were you stationed when the NDE happened?
20. What was your service and rank?
21. What were you doing when you suffered a combat injury?
22. Was this your first combat injury? Yes No
23. Were you able to communicate (on the other side) with other people who were hurt at the same time? Yes No Not Applicable
24. What aspect of the NDE affected you the most?
25. Did you tell any of the medics, nurses about your experience? Yes No Not Applicable
26. If so, what was their response?
27. How did the experience affect the remainder of your service experience?
End of Combat-related-only questions. Everyone should fill in the questions below this.
28. Describe your experience Please describe your experience. Use as much detail as you can and as much space as you need (when you fill up the available space, it will automatically scroll to allow you more):
If any of the following are selected, you haven't answered the corresponding question above. Scroll back or select the description to jump to the question and answer it before submitting.
Check here if you want to get a copy of your answers sent to the e-mail address you gave above.
Submitting this information to IANDS means you agree with the following: I wish the account of my experience to be placed in the IANDS archives. I understand that it will be coded for anonymity and may be read by students or researchers who have been approved in accordance with IANDS' policies for use of the archives. My account may be excerpted or used in full (if I have given permission), or data may be drawn from it in conjunction with any responsible study or project, including but not limited to classroom presentations, lectures or educational programs on near-death studies, or presentations at a professional conference; or as part of an academic paper, thesis or dissertation; or as part of an article for a professional journal or other responsible periodical, or in a book. My name will not be used unless I have given express permission to do so. I also realize that my account may be edited for publication to remove references that might identify me or other people or institutions, and for grammar and spelling.
We suggest that you copy the narrative you typed in or even this whole form into your computer's clipboard, so that if something goes wrong, you won't have lost all your work.
If you have trouble submitting this form or you don't get a "Thank You" message after you press the submit button, contact us.
