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EnvironmentalSurvey- NEPRINTAT

EnvironmentalSurvey- NEPRINTAT - ENVIRONMENTAL SENSITIVITY...

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ENVIRONMENTAL SENSITIVITY: A SURVEY INVESTIGATION OF HUMAN FACTORS This survey is intended to glean information concerning factors in a person’s background and his/her likelihood to be particularly “sensitive” in some way. Please answer honestly and matter of factly. While the nature of this survey makes it necessary to ask some rather personal questions, please know that your responses will be combined with those of other anonymous respondents – and kept confidential. Completed surveys should be mailed to the survey’s author, Michael Jawer, at 8624 McHenry Street, Vienna VA 22180. If you have any questions, please email [email protected] . Thank you very much for participating. _________________________________________________________________ 1) Your age: ____ (years) 2) Gender: Male ____ Female ____ 3) Are you currently (check one): Married ____ Divorced or separated ____ In long-term partnership ____ Single; never married ____ Widowed ____ 4) Do you have children? (biological, not adopted) Yes ____ No ____ 5) If so, what are their ages and genders? Child one: age ______ M ____ or F ____ Child two: age ______ M ____ or F ____ Child three: age ______ M ____ or F ____ Child four: age ______ M ____ or F ____ Child five: age ______ M ____ or F ____ Child six: age ______ M ____ or F ____ 6) Highest educational level attained (check one): Some high school ____ College graduate ____ High school graduate ____ Post graduate work ____ Some college ____ Graduate degree(s) ____ 7) Height: ____ feet ____ inches 8) Weight: _____ pounds
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9) How would you describe your body type? Please mark one of the numbers below: Thin Wide __________________________________________________________________ 1 2 3 4 5 10) Are you right-handed? _____ Left-handed? ____ or Ambidextrous? ____ 11) How would you describe your tendency toward imagination? Please mark one of the numbers below: Think Literally Think Imaginatively __________________________________________________________________ 1 2 3 4 5 12) How would you describe your ‘native’ temperament? Please mark one of the numbers below: Inward Looking Outward Looking __________________________________________________________________ 1 2 3 4 5 13) How would you describe your emotional style (when relating to others)? Please mark one of the numbers below: Restrained Emotive __________________________________________________________________ 1 2 3 4 5 14) Please note your interests or hobbies below: (list up to 4) Hobby or interest one: _____________________________________________ Hobby or interest two: _____________________________________________ Hobby or interest three: _____________________________________________ Hobby or interest four: _____________________________________________ 15) Do you play a musical instrument or do you engage in artistic creation? Yes, extensively ____ Yes, occasionally ____ No ____
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16) How satisfied are you with the level of physical/sexual contact in your life? Please mark one of the numbers below: Unsatisfactory Ideal __________________________________________________________________ 1 2 3 4 5 17) How would you rate the quality of your close personal relationships? Please mark one of the numbers below: Unsatisfactory Ideal __________________________________________________________________ 1 2 3 4 5 18) How many siblings do you have? _____ 19) Please indicate birth order, i.e., what ‘number’ sibling are you?
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