Vision Survey

ONLY ONE COMPLETE SURVEY PER PERSON PLEASE.

(Note: you can choose only one response in each category.)

1. What type of provider did you visit for your eye examination?

[Select one] An independent optometrist (OD) An independent ophthalmologist (MD) An optometrist practicing next to an optical retail location I did not receive an eye examination

2. What type of provider did you visit for your eyewear services (frames, lenses, contact lenses)?

[Select one] An independent optometrist (OD) An independent ophthalmologist (MD) An independent optician A LensCrafters location Another retail optical location I did not receive eyewear services I had LASIK vision correction

3. Did you receive your eye examination and eyewear services (frames, lenses, contact lenses) at the same location?

[Select one] Yes No I did not receive both services

4. Do you plan on using your EyeMed Vision Care Primary Plan again during the year 2001 for additional eyewear purchases?

[Select one] Yes No I did not purchase eyewear on my last visit

5. How did you learn about the EyeMed Vision Care Primary Plan?

[Select one] Through www.fepblue.org Through the BlueCross/BlueShield Service Benefit Plan booklet Through an EyeMed Vision Care mailer sent to my home address Other

These last questions will be used to divide your responses into groups for analysis

1. What is your age?   [Select one] 18 to 24 25 to 34 35 to 44 45 to 49 50 to 54 55 to 59 60 to 64 65 or older

2. What is your gender?   Male Female

3. What is your total family income?   [Select one] $0 to $24,999 $25,000 to $29,999 $30,000 to $34,999 $35,000 to $39,999 $40,000 to $44,999 $45,000 to $54,999 $55,000 to $64,999 $65,000 to $74,999 $75,000 or over

4. What is the last grade of school you've completed? [Select one] Less than high school Some high school High school graduate Some college, technical or business school Four-year college graduate Post-graduate

If you would like to receive the latest updates about eye health, vision products and other services, please enter your e-mail address below. Otherwise, you may leave this section blank.

Email:

Once again, thank you for taking the time to participate in this survey!

This survey is available to all BCBS Service Benefit Plan members and their
eligible dependents. This survey is administered and sponsored by EyeMed Vision
Care, and is not affiliated with Blue Cross and Blue Shield Association. EyeMed Vision
Care assumes all responsibility for survey data and member information submitted via
the web site. Individual survey results are considered proprietary and are the
property of EyeMed Vision Care, although EyeMed Vision Care does reserve the right to
publish overall survey results as it deems necessary and appropriate to EyeMed
Vision Care providers, Blue Cross and Blue Shield Association, potential clients or other
organizations. EyeMed Vision Care will not, under any circumstances sell, rent, or
distribute member information to any other entities, corporations, or organizations
for any reason whatsoever. However, Blue Cross and Blue Shield Association does reserve the
right to receive the member data if requested.