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Values & Community Development Survey

Research Director, R. Michael Fisher, Ph.D. © 2008

The following survey takes 10-15 minutes max. It’s purpose is to collect accurate data on
people’s opinions about human values and development. As an independent social science
researcher, I honor people’s opinions and guarantee the confidentiality in their use for productive
research and positive educational purposes in the future. Survey respondents may choose to
remain anonymous or fill out a brief biography (in part or whole) to accompany the results.

You have been selected because of your known leadership in the current community you live and
participate in. I would appreciate you not sharing this survey with anyone else at this time. I am
planning to survey several people in your community and I do not want them to have seen this
before as it may influence their choices if they do the survey.

In order not to bias your choices on this survey, no more can be explained about this research
until you have completed the following procedures:

(1) on the next page you will find a diagram of “4 different ways to draw & color a
rectangle shape”—examine it briefly, noting the words that describe how each
way was created

(2) on the next page you will find 15 questions with multiple-choice answers only in
regard to the diagram – there is no absolute “right” or “wrong” answer; rather, I wish to
know your opinion to each question as accurately as possible in a very short-time
intuitive response

(3) on the next page you will find 3 questions to fill out and a space for a short summary
of your biography, name, age, etc.

(4) on the next page you will find a Release Form which you are to read carefully; and
if you willingly agree to the conditions of this form then sign your signature, so as to
allow me to use the results in a professional manner.

UPON COMPLETION OF THE SURVEY, ASAP, PLEASE SEND THE RESULTS TO ME in

S.A.S.E. or drop it off, or I’ll pick it up:

507 S. James St., Carbondale, IL 62901

If you have any further questions email me or call:
rmichaelfisher@gmail.com
(618) 529-1166

Thanks for your participation. If you provide me with contact information, I will get back to you
with some of the results in the months and years ahead. Otherwise, I promise not to bug you.

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Diagram for answering multiple choices questions:

Below are 4 different ways (A, B, C, D) of drawing & coloring a

rectangle-shape

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Multiple-choice Questions in regard to the Diagram. Answer each
question fairly quickly but accurately, without changing your answer (opinion) once you write it
down. Choose only one answer for each question (that is, either A or B or C or D). You may
repeat using any of the four choices as much as you like for the set of 15 questions. You may flip
back to look at the Diagram as much as you like in order to answer each question. Total time for
this should not take more than 2-3 minutes.

Use the letter “X” for each of your answers

Q. #1 Which is the normal way of drawing & coloring? This side for Administrative Use Only
A ____ B ____ C ____ D ____

Q. #2 Which is the best?

A ____ B ____ C ____ D ____

Q. #3 Which is the most beautiful?

A ____ B ____ C ____ D ____

Q. #4 Which is the most ugly?

A ____ B ____ C ____ D ____

Q. #5 Which is the most natural, living, alive?

A ____ B ____ C ____ D ____

Q. #6 Which is the most dead, and machine-like?

A ____ B ____ C ____ D ____

Q. #7 Which is the most difficult to do?

A ____ B ____ C ____ D ____

Q. #8 Which is most like you, your personality?

A ____ B ____ C ____ D ____

Q. #9 Which is the most like your parents/caregivers?

A ____ B ____ C ____ D ____

Q. #10 Which is the most artistic and creative?

A ____ B ____ C ____ D ____

Q. #11 Which is the most healthy?

A ____ B ____ C ____ D ____

Q. #12 Which has the most fear in it?

A ____ B ____ C ____ D ____

Q. #13 Which is the most fearless?

A ____ B ____ C ____ D ____

Q. #14 Which is the most like God, Spirit, or Creation?

A ____ B ____ C ____ D ____

Q. #15 Which is most like the community you live in?

A ____ B ____ C ____ D ____

Q. #16 Which is the most violent?

A____ B ____ C ____ D ____
Finish next 2 pages
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Complete the following 3 questions (short answers):

Mark with an “X” to fill in blanks for Yes or No

Otherwise, print clearly or type out your answers.

1. Have you ever seen or heard of this survey and the diagram before
filling out this survey? Yes____ No ______ (If yes, specify)

2. In the community (town, city) where you live, who (in your view) is
the most fearless and spiritually mature person? (you may enter your
own name here if that is your true opinion)

_______________________________ Why do you think so?

_____________________________________________________

______________________________________________________

3. Would you like to see more “fearless leadership” in your

community now and in the future? Yes ______ No ______

Brief Biographic Information (Remember you can chose to remain anonymous (see
next page “Research Release Form”) and/or fill out as much as you wish to share with me, as
director of this research study):

I suggest you give your full name, contact info.,, age, gender, no. of years in this community
(town, city), and any data about your religious or faith commitments, health, spiritual and/or
physical, emotional and mental practices, political persuasion, your race or ethnic background,
profession, family and marriage or single status, etc.

One more page to fill out

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Research Release Form

Print or write clearly

Read carefully, and if you agree with the conditions herein, sign below and return
a copy of this document and survey results to (R. Michael Fisher, Research
Director, 507 S. James St., Carbondale, IL 62901)

I _________________________________________ (print your full name)

declare that all information in this survey (“Values & Community Development

Survey” developed by R. Michael Fisher ©2008) be released to the Director of

Research (R. Michael Fisher, Ph.D. ) for and only for productive research and

positive educational purposes. I hereby agree, by signing below, to allow the

Director of Research (hereafter “Director”) to freely use the enclosed survey

results professionally, and agree to having no ownership rights to the data

or to proceed in any way to inhibit the use of the data, nor to act to secure any

payment or fees involving this research and its uses by the Director and/or from

those whom the Director gives permission to utilize this data.

If you would like your name and identity kept anonymous by the Director of

Research hereafter, please mark an “X” here ________ (if not, leave blank).

Survey participant _______________________________(signature)

Date survey completed and date signed: _________________

Research Director:

Thank You.