Pre-TM

Question Title

* 1. Survey ID info

 Important: Names are only for matching pre and post tests. No individual data will ever be shared. We will only share analysis of group data and keep your survey information completely private.

PURPOSE OF THIS PROGRAM EVALUATION
You have been asked to take part in a program evaluation to learn more about how Transcendental Meditation (TM) may affect you.

WHAT YOU WILL BE ASKED TO DO
If you agree to be in this evaluation, you will complete survey questions before you receive TM instruction, and then complete the same survey questions after a certain time following your ™ instruction.

HOW LONG THE STUDY WILL LAST
The evaluation will take around 10-15 minutes to fill out. You will be invited to fill out the same surveys 1 month, 3 months, and 6 months after your TM instruction.

THE RISKS OF PARTICIPATING, AND WHAT WE DO TO MAKE THOSE RISKS AS SMALL AS POSSIBLE
There is a very small risk that confidential data will be compromised. We will minimize this risk by ensuring that only David Lynch Foundation research staff directly involved in the evaluation will have access to the evaluation’s data/files. The only risks with answering these survey questionnaires that you may feel emotional discomfort when answering questions about your emotional state. If you feel discomfort, you may stop answering questions completely without penalty, or any loss of benefits or and/or access to services at the David Lynch Foundation.

KEEPING YOUR INFORMATION CONFIDENTIAL
The David Lynch Foundation will follow all applicable federal and state laws that protect  personal information including maintaining appropriate physical, electronic, and procedural safeguards. Identifying information is confidential and will not be shared or discussed with anyone outside of the approved program evaluators and data collectors. Identifying information will be kept separate from data collected and will only be used to match pre and post test data. All collected data for this project will be securely stored in lockable locations, secure computer files, or on computer servers accessible only to the approved and trained researchers and authorized staff. The information collected will be stored for a period of five years, as recommended by the American Psychological Association. When it is destroyed, this will be done by shredding of paper files and deletion of electronic files.

Your responses will be kept as confidential as possible with the following exception: the researcher is required by law to report to the appropriate authorities, suspicion of harm to yourself, to children, or to others.

This program evaluation is designed to inform program effectiveness and process of continual improvement. Analytic summaries and diagrams of the data may be included in publication materials for dissemination to the community, participants, and policymakers where relevant.

INCENTIVES
Your participation in this program evaluation is completely voluntary. You will receive no incentive for your participation.

LEGAL RIGHTS
You will not lose any of your legal rights by signing this consent form.

BENEFITS
Although you will receive no direct benefits from participating in this evaluation, this evaluation may help the David Lynch Foundation understand and improve (the purpose of instruments) better.

YOUR RIGHT TO WITHDRAW FROM THE PROJECT
Your participation in the program evaluation is entirely voluntary and your decision about whether or not to participate will involve no penalty or loss of benefits you might otherwise receive. It will not affect your access to services at the David Lynch Foundation. If you decide to participate, you can stop participating at any time without penalty.
CONTACT INFORMATION
If you have questions about the research at any time, if you think you may have been harmed by taking part in this evaluation, if you would like to offer input, or if you have a visual or other impairment and require this material in another format, please contact Sean Slifer by email: sean@davidlynchfoundation.org, or by phone: 212-644-9880

PERMISSION FOR PARTICIPATION IN RESEARCH
I have read this form and the program evaluation has been explained to me. I have been given the opportunity to ask questions and my questions have been answered. If I have additional questions, I have been told whom to contact.

Permission Summary
·   You are being asked to give your permission to fill out surveys as part of a program evaluation.
·   You will be asked to fill out the survey once before you learn TM, and again 1 month after, 3 months after, and 6 months after you learn TM.
·   Your participation is completely voluntary. You can stop answering at any time.
·   All information that you share with the David Lynch Foundation will remain confidential and any information that could individually identify you will not be shared.

Question Title

* 2. I consider myself ________

Question Title

* 3. Military status:

Question Title

* 4. Are you currently active duty in the military?

Question Title

* 5. In the past month, how much were you bothered by:

  Not at all A little bit Moderately Quite a bit Extremely
1. Repeated, disturbing, and unwanted memories of a stressful experience?
2. Repeated, disturbing dreams of a stressful experience?
3. Suddenly feeling or acting as if a stressful experience were actually happening again (as if you were actually back there reliving it)?
4. Feeling very upset when something reminded you of a stressful experience?
5. Having strong physical reactions when something reminded you of a stressful experience (for example, heart pounding, trouble breathing, sweating)?
6. Avoiding memories, thoughts, or feelings related to a stressful experience?
7. Avoiding external reminders of a stressful experience (for example, people, places, conversations, activities, objects or situations)?
8. Trouble remembering important parts of a stressful experience?
9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?
10. Blaming yourself or someone else for a stressful experience or what happened after it?
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?
12. Loss of interest in activities that you used to enjoy?
13. Feeling Distant or cut off from other people?
14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
15. Irritable behavior, angry outbursts, or acting aggressively?
16. Taking too many risks or doing things that could cause you harm?
17. Being "superalert" or watchful or on guard?
18. Feeling jumpy or easily startled?
19. Having difficulty concentrating?
20. Trouble falling or staying asleep?

Question Title

* 6. During the past 7 days:

  Rarely or none of the time (less than 1 day) Some or a little of the time (1-2 day) Occasionally or a moderate amount of the time (3-4 days) Most or all of the time (5-7 days)
1. You were bothered by things that usually don't bother you.
2. You did not feel like eating; your appetite was poor.
3. You felt that you could not shake off the blues even with help from your family or friends.
4. You felt that you were just as good as other people.
5. You had trouble keeping your mind on what you were doing.
6. You felt depressed.
7. You felt that everything you did was an effort.
8. You felt hopeful about the future.
9. You thought your life had been a failure.
10. You felt fearful.
11. Your sleep was restless.
12. You were happy.
13. You talked less than usual.
14. You felt lonely.
15. People were unfriendly.
16. You enjoyed life.
17. You had crying spells.
18. You felt sad.
19. You felt that people disliked you.
20. You could not get "going".

Question Title

* 7. How long did it usually take for you to fall asleep during the past 4 weeks?

Question Title

* 8. On average, how many hours did you sleep each night during the past 4 weeks? Write in number of hours per night:

Question Title

* 9. How often during the past 4 weeks did you...

  All of the Time Most of the time A Good Bit of the Time Some of the Time A Little of the Time None of the Time
1. feel that your sleep was not quiet (moving restlessly, feeling tense, speaking, etc., while sleeping)?
2. get enough sleep to feel rested upon waking in the morning?
3. awaken short of breath or with a headache?
4. feel drowsy or sleepy during the day?
5. have trouble falling asleep?
6. awaken during your sleep time and have trouble falling asleep again?
7. have trouble staying awake during the day?
8. snore during your sleep?
9. take naps (5 minutes or longer) during the day?
10. get the amount of sleep you needed?

T