Foundational Value Study

                                        Consent Form

    This form asks for your consent to participate in a psychological research study. The study is on the topic of wisdom, and is being conducted by Leonard A. Jason, Ph.D. The general purpose of this study is to identify to better define wisdom and its relationship to measures of support, coping, optimism, and stress.  Please be informed that:

1. Your participation in the study is fully voluntary. You have the right to stop at any time, and you will not be penalized for this in any way.

2. All information you provide in the study will be kept strictly confidential, and any report of the study will not identify you personally in any way.

3. At the completion of the study, you will be given a thorough explanation of the research techniques, possible publication and scientific impact of the study.

4. Your participation will take no longer than 50 minutes.

5. In signing this form, you certify that you are 18 years of age or older.

If you have any questions, please feel free to ask them. And if you desire information in the future regarding your participation in the study, feel free to contact the experimenter Leonard Jason (773-325-2018) or chair of the Committee on the Use of Human Subjects, Dr. Kathy Grant (773-325-4241).

Typing your name below indicates that you have read the information provided above and agree to participate in this study.
 

Your First Name: 
Your Last Name: 
Social Security Number:
Today's Date(month/day/year): 

I hereby certify that the above information was read by the participant and that requested explanations were given concerning the study.

Oct 20, 1999                         Leonard Jason, Ph.D.


PART I

1. Your Age Now?
under 20 years old
21-25 years
26-30 years
31-35 years
36-40 years
41-50 years
51-60 years
61-70 years
71 years and older

2. To which of the following U.S. census groups do you belong?
African American
White
Native American
Asian or Pacific Islander
Multi-racial
Other  Please specify

3. Are you of Latino or Hispanic origin?
Yes
No

4. What is your religion?
Catholic
Jewish
Protestant
Islam
No religious affiliation
Other       Please specify 

5.  Are you male or female?
Female
Male

6.  Are you currently married, or are you separated, widowed, or  divorced, or have you ever    been married?
Married
Separated
Widowed
Divorced
Never married

7. Do you have any children?
Yes
No

8. If you have children, how many do you have?
One
Two
Three
Four or more

9. Do you have either a high school degree, GED, college degree, or a graduate degree?
Less than high school
High school degree or GED
Partial college (at least one year) or specialized training
Standard college degree
Graduate professional degree including masters and doctorate
 

10. Check the category below that best describes your work status.
Housekeeper
Working part-time
Working full-time
Unemployed
On disability or sick leave
Retired
In school

11. If you are currently working, what is your current occupation?
Farm laborer/menial service worker
Unskilled worker
Machine operator, semiskilled worker
Skilled manual worker, craftsman, tenant farmer
Clerical or sales worker
Technician, semiprofessional, small business owner
Manager, minor professions
Administrator, proprietor of medium sized business
Higher executive, proprietor of large business, major professional


PART II

We are interested in finding out about your  values and how they might relate to your lifestyle and protective health behaviors. For the items below, please answer the questions.
 
 
How many minutes do you engage in the following activities each day?

                           Use the following scale to answer the questions below:
                               1=not at all, 2= up to 30 minutes, 3= up to one hour,
                      4= up to two hours, 5= up to three hours, 6= four hours or more		  
1. Exercise 1 2 3 4 5 6 
2. Watching TV or cable 1 2 3 4 5 6 
3. Playing video games 12 3 4 5 6 
4. Watching VCR 12 3 4 5 6 
5. Using the internet 1 2 3 4 5 6 
6. Reading newspapers or magazines 1 2 3 4 5 6 
7. Reading books 1 2 3 4 5 6 
8. Listening to the radio 1 2 3 4 5 6 

9.  What is the general status of your health?
Excellent
Moderately good
Ok, but not very good or very bad
Not good
Very bad

10. When you are in the automobile, do you use your seat belt?
Yes
No


PART III

Keep in mind that there are no right or wrong answers. Please answer honestly and try to answer each question. Remember that all of your answers are completely confidential.
 
Foundational Value Scale

For each of the following, please indicate whether you feel you have the quality or characteristic. Use the scale from 1 to 5, where 1 means you do not at all have the quality or characteristic, and 5 means you feel you definitely have the quality or characteristic.
1. Openness (can accommodate
    to whatever experiences that arise) 		 1 2 3 4 5 
2. Spontaneity (all that one does 
    happens naturally, without effort)		 1 2 3 45 
3. Animation (rapture, joy, hope,
    and happiness)		 1 2 3 4 5 
4. Harmony (balanced and 
    centered within) 		 1 2 3 4 5 
5. Flow (so involved in an activity
    that nothing else seems to matter)		 1 2 3 4 5
6. Uninhibited imagination and 
    creativity		 1 2 3 4 5 
7. Freedom from greed, envy,
    jealousness, and hostility		 12 3 4 5 
8. Positive self-esteem and self love 1 2 3 4 5 
9. Gratitude and appreciation 1 2 3 4 5 
10. Appreciation for things as 
      they are, without embellishment		 1 2 3 4 5
11. Universe is perceived as friendly 1 2 3 4 5 
12. Total attention to what is being
      looked at		 1 2 3 4 5 
13. Perception is desireless,
     unselfish, and detached		 1 2 3 4 5 
14. Compassion and warmth for others 1 2 3 4 5 
15. All life is seen as interconnected 1 2 3 4 5 
16. Demonstrates a concern for the
     health of the environment		 123 4 5 
17. Feels love, fellowship, or union
     with god		 1 2 3 4 5 
18. Chooses activities in which
     fulfillment is found		 1 2 3 4 5 
19. Sees meaning and purpose in life 1 2 3 4 5 
20. Experiences an underlying unity in life 1 2 3 4 5 
21. Capacity to cope with  uncertainty 1 2 3 4 5 
22. Ability to frame an event in 
     a larger context		 1 2 3 4 5 
23.  Intelligence 1 2 3 4 5 
24. Childlike wonder and awe 1 2 3 4 5 
25. Good judgment  1 2 3 4 5 
26. Humor 1 2 3 4 5 
27. Financial success  1 2 3 4 5 
28. Being in the present  1 2 3 4 5 
29. Kindness  1 2 3 4 5 
30. Problem solving ability  1 2 3 4 5 
31. Social justice orientation 1 2 3 4 5 
32. Calm and subdued mind  1 23 45 
33. Reverence for nature  1 2 3 4 5 
34. Living a spiritual life  1 2 3 4 5 
35. Charisma  1 2 3 4 5 
36. Genius  1 2 3 4 5 
37. Good teacher (inspires and instructs) 1 2 3 4 5 
38. Gift of prophesy  1 2 3 4 5 


PART IV
 
Marlowe

Listed below are a number of statements concerning personal attitudes and traits. Read each item and decide whether the statement is true or false as it pertains to you.

                                                1 = True; 2 = False
 
1. Before voting I thoroughly investigate the qualifications of all the candidates. 1 2 
2. I never hesitate to go out of my way to help someone in trouble. 1 2 
3. It is sometimes hard for me to go on with my work if I am not encouraged. 1 2 
4. I have never intensely disliked anyone. 1 2 
5. On occasion I have had doubts about my ability to succeed in life. 1 2 
6. I sometimes feel resentful when I don't get my way. 1 2 
7. I am always careful about my manner of dress. 1 2 
8. My table manners at home are as good as when I eat out in a restaurant. 1 2 
9. If I could get into a movie without paying and be sure I was not seen, I would probably do it. 1 2 
10. On a few occasions, I have given up doing something because I thought too little of my ability. 1 2 
11. I like to gossip at times. 1 2 
12. There have been times when I felt like rebelling against people in authority even though I knew they were right. 1 2 
13. No matter who I'm talking to, I'm always a good listener. 1 2 
14. I can remember "playing sick" to get out of something. 1 2 
15. There have been occasions when I took advantage of someone. 1 2 
16. I'm always willing to admit it when I make a mistake. 1 2 
17. I always try to practice what I preach. 1 2 
18. I don't find it particularly difficult to get along with loud-mouthed, obnoxious people. 1 2 
19. I sometimes try to get even, rather than forgive and forget. 1 2 
20. When I don't know something I don't at all mind admitting it. 1 2 
21. I am always courteous, even to people who are disagreeable. 1 2 
22. At times I have really insisted on having things my own way. 1 2 
23. There have been occasions when I felt like smashing things. 1 2 
24. I would never think of letting someone else be punished for my wrongdoings. 1 2 
25. I never resent being asked to return a favor. 1 2 
26. I have never been irked when people expressed ideas very different from my own. 1 2 
27. I never make a long trip without checking the safety of my car. 1 2 
28. There have been times when I was quite jealous of the good fortune of others. 1 2 
29. I have almost never felt the urge to tell someone off. 1 2 
30. I am sometimes irritated by people who ask favors of me. 1 2 
31. I have never felt that I was punished without cause. 1 2 
32. I sometimes think when people have a misfortune they only got what they deserved. 1 2 
33. I have never deliberately said something that hurt someone's feelings. 1 2 

PART V

                                            Social Support Questionnaire (SSQ6)

    The following questions ask about people in your environment who provide you with help or support. Each question has two parts. For the first part, list all the people you know, EXCLUDING YOURSELF, whom you can count on for help or support in the manner described. Give the persons' initials and their relationship to you. LIST NO MORE THAN 9 PERSONS.

    For the second part, use that rating scale provided to note HOW SATISFIED you are with the overall support you have for the area considered in the previous question. If you have no support for a question, mark "NO ONE", but rate your level of satisfaction as you would otherwise. Please answer all of the questions as best you can. All of your responses will be kept confidential.


1. Who can you really count on to be DEPENDABLE when you need help?
    (Just write the initials of the person's name in the spaces below):

= NO ONE    1)          4)           7)
                                  2)          5)            8)
                                  3)          6)            9)

a. How satisfied are you?

6         5             4         3              2               1
very         fairly           a little        a little            fairly               very
satisfied    satisfied      satisfied     dissatisfied     dissatisfied      dissatisfied
 

2. Who can you really count on to help you feel more relaxed when you are under pressure or tense?
= NO ONE    1)          4)           7)
                                  2)          5)            8)
                                  3)          6)            9)

a. How satisfied are you?

6         5             4         3              2               1
very         fairly           a little        a little            fairly               very
satisfied    satisfied      satisfied     dissatisfied     dissatisfied      dissatisfied

3. Who accepts you totally, including both your worst and your best points?
= NO ONE    1)          4)           7)
                                  2)          5)            8)
                                  3)          6)            9)

a. How satisfied are you?

6         5             4         3              2               1
very         fairly           a little        a little            fairly               very
satisfied    satisfied      satisfied     dissatisfied     dissatisfied      dissatisfied
 

4. Who can you really count on to care about you, regardless of what is happening to you?
= NO ONE    1)          4)           7)
                                  2)          5)            8)
                                  3)          6)            9)
 

a. How satisfied are you?

6         5             4         3              2               1
very         fairly           a little        a little            fairly               very
satisfied    satisfied      satisfied     dissatisfied     dissatisfied      dissatisfied
 

5. Who can you really count on to help you feel better when you are feeling generally down-in-the-dumps?
= NO ONE    1)          4)           7)
                                  2)          5)            8)
                                  3)          6)            9)

a. How satisfied are you?

6         5             4         3              2               1
very         fairly           a little        a little            fairly               very
satisfied    satisfied      satisfied     dissatisfied     dissatisfied      dissatisfied
 

6. Who can you count on to console you when you are very upset?
= NO ONE    1)          4)           7)
                                  2)          5)            8)
                                  3)          6)            9)

a. How satisfied are you?

6         5             4         3              2               1
very         fairly           a little        a little            fairly               very
satisfied    satisfied      satisfied     dissatisfied     dissatisfied      dissatisfied


PART VI
 
COPE
We are interested in how people respond when they confront difficult or stressful events in their lives. There are lots of ways to try to deal with stress. This questionnaire asks you to indicate what YOU generally do and feel, when YOU experience stressful events. Obviously, different events bring out somewhat different responses, but thing about what you USUALLY do when you are under a lot of stress. Please treat each item separately from every other item, there are no right or wrong answers, and responses should indicate what YOU do rather than what "most people" do.

                                     Please choose from the responses listed below.
                                     1 = I usually don't do this at all
                                     2 = I usually do this a little bit
                                     3 = I usually do this a medium amount
                                     4 = I usually do this a lot.
 
1. I talk to someone about how I feel. 1 2 3 4 
2. I look for something good in what is happening.  1 2 3 4 
3. I learn to live with it. 1 2 3 4 
4. I seek God's help. 1 2 3 4 
5. I get upset and let my emotions out. 1 2 3 4 
6. I refuse to believe that it has happened. 1 2 3 4 
7. I give up the attempt to get what I want. 1 2 3 4 
8. I try to get emotional support from friends or relatives. 1 2 3 4 
9. I try to see it in a different light, to make it seem more positive. 1 2 3 4 
10. I accept that this has happened and that it can't be changed. 1 2 3 4 
11. I put my trust in God. 1 2 3 4 
12. I let my feelings out. 1 2 3 4 
13. I pretend that it hasn't really happened. 1 2 3 4 
14. I just give up trying to reach my goal. 1 2 3 4 
15. I discuss my feelings with someone. 1 2 3 4 
16. I learn something from the experience. 1 2 3 4 
17. I get used to the idea that it happened. 1 2 3 4 
18. I try to find comfort in my religion. 1 2 3 4 
19. I feel a lot of emotional distress and I find myself expressing those feelings a lot. 1 2 3 4 
20. I act as though it hasn't even happened. 1 2 3 4 
21. I admit to myself that I can't deal with it, and quit trying. 1 2 3 4 
22. I get sympathy and understanding from someone. 1 2 3 4 
23. I try to grow as a person as a result of the experience. 1 2 3 4 
24. I accept the reality of the fact that it happened. 1 2 3 4 
25. I pray more than usual. 1 2 3 4 
26. I get upset, and am really aware of it. 1 2 3 4 
27. I say to myself, "this isn't real." 1 2 3 4 
28. I reduce the amount of effort I'm putting into solving the problem. 1 2 3 4 

PART VII
 
Perceived Stress Scale

The questions in this scale ask you about your feelings and thoughts during the last month. In each case, please indicate with how often you felt or thought a certain way

              1=never, 2=almost never, 3=sometimes, 4=fairly often, 5=very often
 
1. In the last month, how often have you felt that you were unable to control the important things in your life? 1 2 3 4 5 
2. In the last month, how often have you felt confident about your ability to handle your personal problems? 1 2 3 4 5 
3. In the last month, how often have you felt that things were going your way? 1 2 3 4 5 
4. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them? 1 2 3 4 5 

PART VIII
 
Life Orientation Test
Please answer the following questions about yourself by indicating the extent of your agreement using the following scale:

                                               1 = Strongly disagree
                                               2 = Disagree
                                               3 = Neutral
                                               4 = Agree
                                               5 = Strongly agree
 
1. In uncertain times, I usually expect the best. 1 2 3 4 5 
2. It's easy for me to relax.  1 2 3 4 5 
3. If something can go wrong for me it will. 1 2 3 4 5 
4. I'm always optimistic about my future. 1 2 3 4 5 
5. I enjoy my friends a lot. 1 2 3 4 5 
6. It's important for me to keep busy. 1 2 3 4 5 
7. I hardly ever expect things to go my way. 1 2 3 4 5 
8. I don't get upset too easily. 1 2 3 4 5 
9. I rarely count on good things happening to me. 1 2 3 4 5 
10. Overall, I expect more good things to happen to me than bad. 1 2 3 4 5 


PART IX
 
CESD
Below are a number of statements about the way you might have felt or behaved. Please read each statement and determine how often you have felt this way DURING THE PAST WEEK. All your responses will be kept strictly confidential.

              Use the code below for your answers.

                          1 = Rarely or None of the Time (Less than 1 Day)
                          2 = Some or a Little of the Time (1-2 Days)
                          3 = Occasionally or a Moderate Amount of Time (3-4 Days)
                          4 = Most or All of the Time (5-7 Days). During the past week: 
 
1. I was bothered by things that usually don't bother me. 1 2 34 
2. I did not feel like eating. My appetite was poor. 1 2 3 4 
3. I felt that I could not shake off the blues even with help from my family or friends. 1 2 3 4 
4. I felt that I was just as good as other people.  1 2 3 4 
5. I had trouble keeping my mind on what I was doing. 12 3 4 
6. I felt depressed. 1 2 3 4 
7. I felt that everything I did was an effort. 1 2 3 4 
8. I felt hopeful about the future. 1 2 3 4 
9. I thought my life had been a failure. 1 2 3 4 
10. I felt fearful. 1 2 3 4 
11. My sleep was restless. 1 2 3 4 
12. I was happy. 1 2 3 4 
13. I talked less than usual. 1 2 3 4 
14. I felt lonely. 1 2 3 4 
15. People were unfriendly. 1 2 3 4 
16. I enjoyed life. 1 2 3 4 
17. I had crying spells. 1 2 3 4 
18. I felt sad. 1 2 3 4 
19. I felt that people disliked me. 1 2 3 4 
20. I could not get "going." 1 2 3 4 


PART  X

            Alcohol and Drug Use Questionnaire

1. Have you ever smoked a cigarette (even a puff)?
Yes
No
If yes, how many times have you smoked cigarettes in the last thirty days?
0-5
6-10
11-15
16-20
21 or greater

2. Have you ever used chewing tobacco/snuff?
Yes
No
If yes, how many times have you used it in the last thirty days?
0-5
6-10
11-15
16-20
21 or greater

3. Have you ever smoked cigars?
Yes
No
If yes, how many times have you smoked one in the last thirty days?
0-5
6-10
11-15
16-20
21 or greater

4. Have you ever drank alcohol to get drunk?
Yes
No
If yes, how many times have you used it to get  drunk in the last thirty days?
0-5
6-10
11-15
16-20
21 or greater

5. Have you ever used Marijuana?
Yes
No
If yes, how many times have you used it in the last thirty days?
0-5
6-10
11-15
16-20
21 or greater

6. Have you ever used Crack Cocaine?
Yes
No
If yes, how many times have you used it in the last thirty days?
0-5
6-10
11-15
16-20
21 or greater

7. Have you ever used Powder Cocaine?
Yes
No
If yes, how many times have you used it in the last thirty days?
0-5
6-10
11-15
16-20
21 or greater

8. Have you ever used LSD?
Yes
No
If yes, how many times have you used it in the last thirty days?
0-5
6-10
11-15
16-20
21 or greater

9. Have you ever sniffed glue or solvents?
Yes
No
If yes, how many times have you done so in the last thirty days?
0-5
6-10
11-15
16-20
21 or greater

10. Have you ever taken prescription drugs for fun?
Yes
No
If yes, how many times have you done so in the last thirty days?
0-5
6-10
11-15
16-20
21 or greater

11. Have you ever used "Ecstasy?"
Yes
No
If yes, how many times have you used it in the last thirty days?
0-5
6-10
11-15
16-20
21 or greater

12. Have you ever used methamphetamine?
Yes
No
If yes, how many times have you used it in the last thirty days?
0-5
6-10
11-15
16-20
21 or greater