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

            1.    Preferred: via the questionnaire form below.

            2.    Via e-mail (see e-mail link at the bottom of this page).   E-mailing your account is acceptable, but for research it is much better if we can tabulate the results from your completion of the NDE 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 45 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.  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 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.  All text boxes allow an unlimited amount of text to be entered.

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.  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 researchers, students, or others 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, or part of a published article, or in a book.  Specific identifying information will not be used unless you give express permission to do so.  THANKS!!!

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.  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):

The media regularly contacts NDERF with interest in connecting with those who had near-death experiences and related experiences.  Please make sure that we have your updated e-mail contact.  If you have aol.com as your email service please be sure that we (nderf@nderf.org and blueheron78@yahoo.com) are on your approved sender list - otherwise you may not receive the messages that we e-mail you.
Thanks!

Remember- the questions that have any text 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!

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


Race/Ethnicity (check all that apply):
White/Caucasian    Hispanic    Black    Asian     Native American
Other:



Country of birth:
 


Your current principal occupation (or if retired, indicate that you are currently retired and also state your prior principal occupation):
 

Check all that apply.  Skip if none apply.  In my occupation, I am currently or have been a:
Priest    Minister    Scientist    Physician     Attorney    Nurse     College or University Teacher
 

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

Your condition at time of experience (select best choice):

Your experience included (check all that apply):

Occasionally blue or green font will be used in part of a question for emphasis.  However, please remember that questions with any red font in the question must be answered.  Thanks!

Your religious background at the time of the experience (carefully review all the choices in the list, then select (highlight) the one best response):
Christian- Protestant Christian- Catholic Christian- Mormon Christian- Jehovah's Witness Christian- Other Christian Unaffiliated- Atheist Unaffiliated- Agnostic Unaffiliated- Nothing in particular- Secular unaffiliated Unaffiliated- Nothing in particular- Religious unaffiliated Jewish Other faiths- Unitarian and other liberal faiths Other faiths- New age Native American religion Buddhist Muslim Hindu Do not know No comment Other or several faiths (enter in box below)

Please share any comments that you would like regarding your religious background at the time of the experience.
If "Other or several faiths (enter in box below)" selected above, please describe.



Your religious background currently (carefully review all the choices in the list, then select (highlight) the one best response):
Christian- Protestant Christian- Catholic Christian- Mormon Christian- Jehovah's Witness Christian- Other Christian Unaffiliated- Atheist Unaffiliated- Agnostic Unaffiliated- Nothing in particular- Secular unaffiliated Unaffiliated- Nothing in particular- Religious unaffiliated Jewish Other faiths- Unitarian and other liberal faiths Other faiths- New age Native American religion Buddhist Muslim Hindu Do not know No comment Other or several faiths (enter in box below)

Please share any comments that you would like regarding your current religious background.
If "Other or several faiths (enter in box below)" selected above, please describe.



Do you consider the content of your experience (NOT the possible life-threatening event associated with the experience) to be (select the one best response):
Entirely pleasant   
Entirely distressing    
Both pleasant and distressing   
Neither pleasant nor distressing


Highest level of education (carefully review all the choices in the list, then select (highlight) the one best response).  Non-USA respondents please make a best guess of the response 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.  At the time of your experience was there an associated life-threatening event?
No     Yes     Uncertain
    If yes or uncertain, please describe in detail:



2.  Please describe your experience using as much detail as you can and as much space as you need (scroll bars allow an unlimited amount of writing).  Please also describe the events that occurred both prior to and after the experience.
 


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

4.  How did your highest level of consciousness and alertness during the experience compare to your normal everyday 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 everyday consciousness and alertness, please explain:



5.  Was the experience difficult to express in words?
No     Yes     Uncertain
    If yes or uncertain, please explain.



6.  Were your thoughts speeded up?
No
Faster than usual
Incredibly fast


7.  Were your senses more vivid than usual?
No
More vivid than usual
Incredibly more vivid


8.  Please compare your vision during the experience to your everyday vision that you had immediately prior to the time of the experience.



9.  Please compare your hearing during the experience to your everyday hearing that you had immediately prior to the time of the experience.



10.  Did you feel separated from your body?
No
I lost awareness of my body
I clearly left my body and existed outside it


11.  Did you see or hear any earthly events that were occurring during a time that your consciousness / awareness was apart from your physical / earthly body?
No     Yes     Uncertain
   If yes or uncertain, describe in detail.
   Also, if you saw or heard any earthly events that were occurring during a time that your consciousness / awareness was apart from your physical / earthly body that you later (after your experience) verified either was (or was not) real, please describe:



12.  What emotions did you feel during the experience?



13.  Did you have a feeling of peace or pleasantness?
No
Relief or calmness
Incredible peace or pleasantness


14.  Did you have a feeling of joy?
No
Happiness
Incredible joy


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



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



17.  Did you see, or feel surrounded by, a brilliant light?
No
An unusually bright light
A light clearly of mystical or other-worldly origin


18.  Did you seem to encounter a mystical being or presence, or hear an unidentifiable voice?
No
I heard a voice I could not identify
I encountered a definite being, or a voice clearly of mystical or unearthly origin
  For any response above other than 'No', describe in detail.



19.  Did you see deceased or religious spirits?
No
I sensed their presence
I actually saw them


20.  Did you encounter or become aware of any beings who previously lived on earth who are described by name in religions (for example: Jesus, Muhammad, Buddha, etc.)?
No     Yes     Uncertain
    If yes or uncertain, describe in as much detail as possible.

For questions 21 below, if you encountered or became aware of any beings who previously lived on earth who are described by name in religions (for example: Jesus, Muhammad, Buddha, etc.), please be sure that you entered this in the above question, and do not enter information regarding encountering them in question 21 below.


21.  Did you encounter or become aware of any deceased (or alive) beings?
No     Yes      Uncertain
    If yes or uncertain, describe.  What was the relation of these being(s) to you (for example: acquaintance, friend, family member, pet, etc.)? 
   Also, if you encountered being(s) that you thought were alive at the time of the experience, but they were really deceased at the time of your experience, please describe.



22.  Did you become aware of past events in your life during your experience?
No     Yes     Uncertain
    If yes or uncertain, describe in detail.
   Also, if you later verified that any of the past events in  your life that you became aware of during your experience really did not happen or were not real, describe in detail.



23.  Did scenes from your past come back to you?
No
I remembered many past events
My past flashed before me, out of my control


24.  Did you seem to enter some other, unearthly world?
No
Some unfamiliar and strange place
A clearly mystical or unearthly realm
  For any response above other than "No", describe in detail.



25.  Did time seem to speed up or slow down?
No
Time seemed to go faster or slower than usual
Everything seemed to be happening at once; or time stopped or lost all meaning
  For any response above other than "No", describe.



26.  Did you feel a sense of harmony or unity with the universe?
No
I felt no longer in conflict with nature
I felt united or one with the world


27.  Did you suddenly seem to understand everything?
No
Everything about myself or others
Everything about the universe
  For any response above other than ‘No’, describe.



28.  Did you seem to be aware of things going on elsewhere, as if by ESP?
No
Yes, but the facts have not been checked out
Yes, and the facts have been checked out


29.  Did you reach a boundary or limiting physical structure?
No     Yes     Uncertain
    If yes or uncertain, describe.



30.  Did you come to a border or point of no return?
No
I came to a definite conscious decision to "return" to life
I came to a barrier that I was not permitted to cross; or was "sent back" against my will
  If you selected the above response ‘I came to a definite conscious decision to "return" to life’, please describe and include anything that might have been important in the decision to return to life.



31.  Did scenes from the future come to you?
No
Scenes from my personal future
Scenes from the world's future
  For any response above other than ‘No’, please describe in detail.


 

The following questions 32 - 41 pertain only to what occurred during the actual 'experience' part of what you are sharing.  This is defined as information or awareness that occurred only during the actual ‘experience’.

The ‘experience’ begins at the earlier of the moment that physical consciousness begins or the moment that a non-ordinary aspect of the experience begins.

The ‘experience’ ends at the later of the moment that physical consciousness returns or the moment the non-ordinary aspect of the experience ends.

Most of the questions below will include the comment  ‘ ***experience only ’ as a reminder of the preceding.

The term "specific information" below means information that was definitely received during  your experience that directly applies to the question.



For question 32 below, if you encountered any information / awareness suggesting that there either is (or is not) continued existence after earthly life ("life after death"), please describe in text box.

32.  During your experience, did you encounter any specific information / awareness suggesting that there either is (or is not) continued existence after earthly life (“life after death”) (***experience only)?
No     Yes     Uncertain
    If yes or uncertain, describe in as much detail as possible.

For question 33 below, if you encountered any information / awareness that God or a supreme being either does (or does not) exist, please describe in text box.

33.  During your experience, did you encounter any specific information / awareness that God or a supreme being either does (or does not) exist (***experience only)?
No     Yes     Uncertain
    If yes or uncertain, describe in as much detail as possible.




For question 34 below,  if you encountered any information / awareness that you either did (or did not) exist prior to this lifetime, please describe in text box.

34.  During your experience, did you encounter any specific information / awareness that you either did (or did not) exist prior to this lifetime (***experience only)?
No     Yes     Uncertain
    If yes or uncertain, describe in as much detail as possible.




For question 35 below, if you encountered any specific information / awareness that a mystical universal connection or unity/oneness either does (or does not) exist, please describe in text box.

35.  During your experience, did you encounter any specific information / awareness that a mystical universal connection or unity/oneness either does (or does not) exist (***experience only)?
No     Yes     Uncertain
    If yes or uncertain, describe in as much detail as possible.

36.  During your experience, did you encounter any specific information / awareness regarding earthly life’s meaning or purpose (***experience only)?
No     Yes     Uncertain
    If yes or uncertain, describe in as much detail as possible.



37.  During your experience, did you encounter any specific information / awareness regarding earthly life’s difficulties, challenges, or hardships (***experience only)?
No     Yes     Uncertain
    If yes or uncertain, describe in as much detail as possible.



38.  During your experience, did you encounter any specific information / awareness regarding love (***experience only)?
No     Yes     Uncertain
    If yes or uncertain, describe in as much detail as possible.



39.  During your experience, did you encounter any other specific information / awareness that you have not shared in other questions that is relevant to living our earthly lives (***experience only)?
No     Yes      Uncertain   
    If yes or uncertain, describe in as much detail as possible.



40.  Did you have a sense of knowing special knowledge or purpose (***experience only)?
No     Yes     Uncertain
    If yes or uncertain, discuss and share what you came to know.



41.  What occurred during your experience included (select the one best response) (***experience only):

    Please share any comments that you have about what occurred during your experience and its consistency or non-consistency with the beliefs you had at the time of your experience:



42.  How accurately do you remember the experience in comparison to other life events that occurred around the time of the experience (select the one best response)?

    Please share any comments that you have about the accuracy of your remembrance of your experience in comparison to other life events that occurred around the time of the experience:




Questions 43 - 49 pertain to before or after your experience per the context of the questions.

The following questions are about changes in your life that might have occurred after your experience.  You will be able to share in narrative form about any changes that you might have had after your experience following these questions.  Please read all options carefully, then select the best choice from both the (a) and (b) columns for each question.
 

Please discuss any changes that might have occurred in your life after your experience:

 

All remaining questions pertain to what occurred before, during, or after your experience per the context of the questions.


51.  Did you have any changes in your values or beliefs after your experience that occurred as a result of the experience?
No     Yes     Uncertain
    If yes or uncertain, please describe in detail.



52.  Do you have any psychic, non-ordinary or other special gifts after your experience that you did not have before the experience?
No     Yes     Uncertain
    If yes or uncertain, describe.



53.  Are there one or several parts of your experience that are especially meaningful or significant to you?  Please explain.



54.  Have you ever 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, and if so, how?

55.  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?  Did your knowledge about NDE affect your experience in any way?



56.  What did you believe about 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.



57.  What do you believe about the reality of your experience at the current time (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.



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



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



60.  At any time in your life, has anything ever reproduced any part of the experience?
No     Yes     Uncertain
    If yes or uncertain, describe in detail.



61.  Is there anything else that you would like to add about your experience?



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

63.  What could a national organization with an interest in near death experience (NDE) do that would be of interest to you?



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

   Thanks!!!