G5WJ99 QUESTIONNAIRE

The following questionnaire is part of a study being conducted as a Sociology 300 project.
Please do not write your name on the questionnaire to ensure the confidentiality of your
responses. Thank you for your co-operation.

1. Gender: I am: Male-----------1

Female---------2

2. In what year were you born? 1 9 ___ ___

3. What program of study are you currently enrolled in?

Bachelor of Arts---------------------------01
Bachelor of Business Administration--------02
Bachelor of Education----------------------03
Bachelor of Engineering--------------------04
Bachelor of Music--------------------------05
Bachelor of Science in Nursing-------------06
Bachelor of Science in Human Nutrition-----07
Bachelor of Science in Human Kinetics------08
Bachelor of Science------------------------09
Bachelor of Arts in Information Systems----10
Other--------------------------------------11
If other, please specify______________________________

4. What year of study are you currently in?

Freshman----------------1
Sophomore---------------2
Junior------------------3
Senior------------------4
Other-------------------5
If other, please specify______________________________________

5. Approximately, what was the population of your hometown/or city before

coming to university?

Rural area under 1,000-------1

1,000-4,999------------------2
5,000-9,999------------------3
10,000-19,999-----------------4
20,000-29,999-----------------5
30,000-39,999-----------------6
40,000-49,999-----------------7
50,000 and over---------------8

6. What is your religious affiliation?

Roman Catholic----------01 Jewish------------------07

Anglican----------------02 Buddhist----------------08
United------------------03 Muslim------------------09
Baptist-----------------04 None--------------------10
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Presbyterian------------05 Other-------------------11
Other Protestant--------06 Please specify_________________

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7. Currently, how often do you attend church services?

More than once a week---------------------1

Once every week---------------------------2
2-3 times a month-------------------------3
Once a month------------------------------4
7-10 times a year-------------------------5
2-6 times a year--------------------------6
Once a year-------------------------------7
Never-------------------------------------8

8. What is (or was) the main occupation of your father? (e.g., social worker,
elementary school teacher)?

Job position_______________________________________________________________

Brief job description______________________________________________________

9. What is (or was) the main occupation of your mother? (e.g., high school teacher,
home maker, lawyer)?

Job position________________________________________________________________

Brief job description_______________________________________________________

10. Ann is 50 years old, a cancer patient. She is in the last phase of the disease. It
has been decided by her physician that no treatment options will serve any benefit
to treat her cancer or reduce discomfort. She has left the hospital of her own free
will and wishes to die. The physician prescribes medication for Ann, knowing she
intends to overdose on it. In regards to the physician’s actions, I…

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

11. Ben is 30 years old and has been paralyzed from the neck down as a result of an
accident some years ago. He is bedridden for the rest of his life. He no longer has
control over urine or bowel movements and needs to be fed and cared for. He finds a
passive life in an institution unbearable. Ben wishes to die. The physician
prescribes medication for Ben and sets it up so that he will be able to take it in
overdose amounts himself when he chooses. In regards to the physician’s actions, I…

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

12. Margaret is a 90 year old lady who lives by herself. She has weak sight, arthritis
and can no longer do the things she enjoys. Margaret spends most of her day alone
except an one hour visit from a home care nurse. She is lonely and wishes to die.
The physician prescribes medication for Margaret, knowing she intends to overdose on
it. In regards to the physician’s actions, I…

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

13. Ann is 50 years old, a cancer patient. She is in the last phase of the disease. It
has been decided by her physician that no treatment options will serve any benefit
to treat her cancer or reduce discomfort. She has left the hospital of her own free
will and wishes to die. She has asked her physician to inject a lethal drug into her

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 to bring about her death and the physician has agreed to do it. In regards to the
physician’s actions, I…

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

14. Ben is 30 years old and has been paralyzed from the neck down as a result of an
accident some years ago. He is bedridden for the rest of his life. He no longer has
control over urine or bowel movements and needs to be fed and cared for. He finds a
passive life in an institution unbearable. Ben wishes to die. He asks his physician
to give him a lethal injection to end his life and the physician has agreed to do
it. In regards to the physician’s actions, I…

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

15. Margaret is a 90 year old lady who lives by herself. She has weak sight, arthritis
and can no longer do the things she enjoys. Margaret spends most of her day alone
except an one hour visit from a home care nurse. She is lonely and wishes to die.
She has asked her physician to inject a lethal drug into her to bring about her
death and the physician has agreed to do it. In regards to the physician’s actions,
I…

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

16. I would help a friend fight for the right to die if that was his/her choice.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

17. I would refuse to provide a terminally ill person with a lethal dosage of a drug, if
they request it.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

18. I would rather die than live with a chronic, painful, non-terminal illness.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

19. I would personally give a lethal injection to a terminally ill individual, if

requested by the person.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

20. I would provide emotional support to a terminally ill friend who wished to end
his/her life.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

21. People have the right to take their own life if they are terminally ill.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

22. People have the right to take their own lives if they have suffered a great
financial loss.
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 Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

23. Active euthanasia is defined as an action by a person with the intention of

hastening the death of another person who is terminally ill, or in such a condition
that causes suffering. Active euthanasia is wrong under all circumstances.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

24. Physician-assisted suicide is an action taken by the physician which assists a

person in ending their own life. Physician-assisted suicide should be legalized.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

25. I am in favor of active euthanasia.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

26. I am in favor of physician assisted suicide.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

27. I feel depressed.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

28. I worry about the way I look.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

29. I feel lonely.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

30. I worry about what others think.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

31. I have a tendency to get involved in unhealthy relationships.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

32. I usually avoid talking about my feelings.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

33. I find other people’s moods influence my own mood.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

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34. I occasionally question whether my life is worth living.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

35. My religious beliefs are strong.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

36. I have been “at the bedside” of one who was dying:

Yes--------------1
No---------------2

37. Indicate whether or not anyone from the following categories is currently suffering
from a long time illness or has died following a long period of suffering.

Yes No
Close friend----------------------------_____ _____
Acquaintance----------------------------_____ _____
Immediate family member-----------------_____ _____
Relative--------------------------------_____ _____
Neighbor--------------------------------_____ _____
Other-----------------------------------_____ _____
If other, please specify_____________________________________

38. If yes for any part of question 37, for the person you had the most contact with:
How much time did you spend with that person while he/she was sick?

Lived with------------------------1
Visited every day-----------------2
Visited 2-3 times/week------------3
Visited once a week---------------4
Visited 2-3 times/month-----------5

39. How long was this person ill?

1-2 weeks-----------------1
Less than a month---------2
Less than 6 months--------3
Less than 1 year----------4
1 year or more------------5

40. I would “rather die” than become dependent on my family to care for me.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

41. I believe in a superior being whom I have a relationship with.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

42. I would “rather die” than live in a nursing home.

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 Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

43. If a family member had cancer and decided against having chemotherapy, I would
question their decision.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

44. God would not allow anyone to have more pain than they could handle.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

45. I love to get up each day to live life to the fullest.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

46. I believe that a “higher being” is there for those in times of anguish and
suffering.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

47. I often over commit myself.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

48. I love to be the center of attention.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

49. When children are young, a mother’s place is in the home.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

50. I worry about dating/relationship problems.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

51. Capital punishment is acceptable if the offender can not be rehabilitated.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

52. Capital punishment is never acceptable.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

53. Abortion is okay in the case of unplanned pregnancy.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

54. Abortion is okay in the case of rape.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

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55. My life is meaningless.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

56. My religious beliefs greatly influence decisions I make.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

57. When I face difficult times in my life, I believe “a greater force” will meet me
half way.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

58. If I were diagnosed with a disabling illness, my biggest fear would be of becoming
dependent on others.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

59. If a terminally ill person refuses to eat to hasten death, healthcare workers should
implement alternative ways to provide nutrition.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

60. I believe that I am greatly needed in this world.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

61. Abortion should be entirely the personal choice of the woman involved.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

62. I believe in “life after death”.

Strongly Disagree 1 2 3 4 5 6 7 8 9 Strongly Agree

*** Thank you ***