Cultic Studies Journal, Vol. 12, No. 2, 1995, page 16
8. Month and year entered the group ____________________
9. Month and year left the group ________________________
10. Which of the following most influenced your decision to leave the group? Check one:
10.1 _____It was primarily my own decision.
10.2 _____I was strongly influenced by an exit counseling.
10.3 _____I was strongly influenced by another group member.
10.4 _____I was strongly influenced by someone other than above (such as family
member, member of the clergy, friend).
10.5 _____None of the above. Please explain: ________________________________
11. Which of the following best describes your religious preference at this time? Check one:
11.1 _____Catholic
11.2 _____Protestant
11.3 _____Jewish
11.4 _____Other Please write in: _________________________________________
11.5 _____No religious preference at this time
12. Which best describes your ancestral origins? Check one:
12.1 _____European
12.2 _____Asian
12.3 _____African
12.4 _____Central American
12.5 _____South American
12.6 _____Native American
12.7 _____Mixed (two or more of the above)
12.8 _____Other Please explain: _________________________________________
13. Which best describes your employment status at this time?
13.1 _____Fully employed (30 or more hours per week)
13.2 _____Part-time employment (1 to 29 hours per week)
13.3 _____Not employed, and seeking work
13.4 _____Not employed, and not seeking work at the moment
13.5 _____Full-time homemaker
14. Please write in the title of your current or last paid job _______
15. How many years of education have you completed? _______
16. Which best describes your educational status at this time?
16.1 _____Full-time student
16.2 _____Part-time student
16.3 _____Not in school at this time
17. Please write in your educational major or specialization (at this time or when you were
last in school or college) ________________________________________________
You are welcome to write comments or suggestions below about this personal
information form or about any question, or to discuss them with me.
Thank you very much for your cooperation.
A.B.C. Dee, Ph.D.
Professor of Psychology
University of Podunk
~~~~~~~~~~
Comment for Researchers
Depending on your research purposes, you may wish to add items such as parents‟
education, occupations, religious preferences, and income informant‟s physical and mental
8. Month and year entered the group ____________________
9. Month and year left the group ________________________
10. Which of the following most influenced your decision to leave the group? Check one:
10.1 _____It was primarily my own decision.
10.2 _____I was strongly influenced by an exit counseling.
10.3 _____I was strongly influenced by another group member.
10.4 _____I was strongly influenced by someone other than above (such as family
member, member of the clergy, friend).
10.5 _____None of the above. Please explain: ________________________________
11. Which of the following best describes your religious preference at this time? Check one:
11.1 _____Catholic
11.2 _____Protestant
11.3 _____Jewish
11.4 _____Other Please write in: _________________________________________
11.5 _____No religious preference at this time
12. Which best describes your ancestral origins? Check one:
12.1 _____European
12.2 _____Asian
12.3 _____African
12.4 _____Central American
12.5 _____South American
12.6 _____Native American
12.7 _____Mixed (two or more of the above)
12.8 _____Other Please explain: _________________________________________
13. Which best describes your employment status at this time?
13.1 _____Fully employed (30 or more hours per week)
13.2 _____Part-time employment (1 to 29 hours per week)
13.3 _____Not employed, and seeking work
13.4 _____Not employed, and not seeking work at the moment
13.5 _____Full-time homemaker
14. Please write in the title of your current or last paid job _______
15. How many years of education have you completed? _______
16. Which best describes your educational status at this time?
16.1 _____Full-time student
16.2 _____Part-time student
16.3 _____Not in school at this time
17. Please write in your educational major or specialization (at this time or when you were
last in school or college) ________________________________________________
You are welcome to write comments or suggestions below about this personal
information form or about any question, or to discuss them with me.
Thank you very much for your cooperation.
A.B.C. Dee, Ph.D.
Professor of Psychology
University of Podunk
~~~~~~~~~~
Comment for Researchers
Depending on your research purposes, you may wish to add items such as parents‟
education, occupations, religious preferences, and income informant‟s physical and mental
