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WORK LIFE SURVEY

1.	Please indicate which of the following "Lunch and Learn" topics that would be of interest to you.
	Ergonomics Migraines Pre and Post Natal Fitness Stress Management Parenting Nutrition/Diet Breast Cancer Education and Screening Prostate Cancer Education and Screening Other: Explain in the Comments field below.

2.	Please indicate the 3 Well Being Programs that would be of the most value or importance to you.
	Screenings for cholesterol, blood pressure and glucose Chair Massage On site "Med Check" (primary care for acute illness) Yoga class First Aid/CPR Course Smoking Cessation Program Nutrition/Weight Loss Program Other: Please explain in the Comments field below.

3.	Please indicate the 3 Work/Life Programs that would be of most value or importance to you.
	ATM Machine on site Dry Cleaning Service Day Care Support Sabbatical Program Community Outreach Program Take Home Dinners Vacation Buy Back Program Flexible Work Arrangements Part Time/Job Share Opportunities Other: Please explain in the Comments field below.

4.	Would you be interested in participating in a focus group discussion on Work/Life balance programs ?
	Yes No
5.	Have you utilized the "Life Works" program?
	Yes No Don't know what it is
6.	How would you define work/life balance? Please explain in the Comments field below?

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BLUE CROSS SURVEY

1.	What is the approximate total number of times that you and your dependents have used this plan since January ?
	None 1-2 3-5 6-10 >10
2.	Please indicate the reason(s) for having utilized the plan?
	Routine Checkups Specialist Visits Emergency Care Planned Hospitalization Other: Please explain in the Comments field below

3.	How would you rate your experience with the Blue Cross Blue Shield PPO plan with regard to claims processing, plan coverage, extent of network, customer service, etc ?
	a. Very Satisfied b. Somewhat Satisfied c. Somewhat Dissatisfied d. Very Dissatisfied
4.	If you answered "c" or "d" to the previous question, please indicate the nature of the problem(s) that you have experienced.
	Provider's office told that coverage was cancelled 1/1/02 Did not receive Coordination of Benefits ("other insurance") letter Needed to provide COB information several times before file was updated Provider not in network Coverage not as expected Claims not paid in timely manner Claims denied Customer Service was not helpful or "knowledgeable Other: Please explain in the Comments field below

5.	Approximately how much of your own time was spent on resolving the problems you experienced ?
	Less than 1/2 hour 1/2 to 1 hour 1 - 2 hours More than 2 hours
6.	How were the problems ultimately resolved ?
	Provider's office handled it. Assistance from Blue Cross Blue Shield Customer Service Line Assistance from HR Numerous calls and people involved (self, Customer Service, HR, etc.) Still unresolved
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UNITED BEHAVIORAL HEALTH SURVEY

1.	What is the approximate total number of times that you and your dependents have used this plan since January ?
	None 1-2 3-5 6-10 >10
2.	How would you rate your experience with the United Behavioral Health plan with regard to claims processing, plan coverage, extent of network, customer service, etc ?
	a. Very Satisfied b. Somewhat Satisfied c. Somewhat Dissatisfied d. Very Dissatisfied
3.	If you answered "c" or "d" to the previous question, please indicate the nature of the problem(s) that you have experienced.
	Problem with member status - "not covered" Provider not in network Coverage not as expected Claims not paid in timely manner Claims denied Customer Service was not helpful or "knowledgeable Other: Please explain in the Comments field below

4.	Approximately how much of your own time was spent on resolving the problems you experienced ?
	Less than 1/2 hour 1/2 to 1 hour 1 - 2 hours More than 2 hours
5.	How were the problems ultimately resolved ?
	Provider's office handled it. Assistance from United Behavioral Health Customer Service Line Assistance from HR Numerous calls and people involved (self, Customer Service,HR, etc.) Still unresolved
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FALLON SURVEY

What is the approximate total number of times that you and your dependents have used this plan since January ?

If None, Select Button on Left
1-2
3-5
6-10
>10

Please indicate the reason(s) for having utilized the plan?

Routine Checkups
Specialist Visits
Emergency Care
Planned Hospitalization

Other: Please explain in the Comments field below

How would you rate your experience with the Fallon HMO plan with regard to claims processing, plan coverage, extent of network, customer service, etc ?

a. Very Satisfied
b. Somewhat Satisfied
c. Somewhat Dissatisfied
d. Very Dissatisfied

If you answered "c" or "d" to the previous question, please indicate the nature of the problem(s) that you have experienced.

Provider not in network
Problem with referral process
Coverage not as expected
Claims not paid in timely manner
Claims denied
Customer Service was not helpful or "knowledgeable

Other: Please explain in the Comments field below

Approximately how much of your own time was spent on resolving the problems you experienced ?

Less than 1/2 hour
1/2 to 1 hour
1 - 2 hours
More than 2 hours

How were the problems ultimately resolved ?

Provider's office handled it.
Assistance from Fallon Customer Service Line
Assistance from HR
Numerous calls and people involved (self, Customer Service, HR, etc.)
Still unresolved

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TUFTS SURVEY

1.	What is the approximate total number of times that you and your dependents have used this plan since January ?
	If None, Select Button on Left 1-2 3-5 6-10 >10
2.	Please indicate the reason(s) for having utilized the plan?
	Routine Checkups Specialist Visits Emergency Care Planned Hospitalization Other: Please explain in the Comments field below


3.	How would you rate your experience with the Tufts HMO plan with regard to claims processing, plan coverage, extent of network, customer service, etc ?
	a. Very Satisfied b. Somewhat Satisfied c. Somewhat Dissatisfied d. Very Dissatisfied
4.	If you answered "c" or "d" to the previous question, please indicate the nature of the problem(s) that you have experienced.
	Provider not in network Problem with referral process Coverage not as expected Claims not paid in timely manner Claims denied Customer Service was not helpful or "knowledgeable Other: Please explain in the Comments field below

5.	Approximately how much of your own time was spent on resolving the problems you experienced ?
	Less than 1/2 hour 1/2 to 1 hour 1 - 2 hours More than 2 hours
6.	How were the problems ultimately resolved ?
	Provider's office handled it. Assistance from Tufts Customer Service Line Assistance from HR Numerous calls and people involved (self, Customer Service,HR, etc.) Still unresolved
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SUPERIOR VISION SURVEY

1.	What is the approximate total number of times that you and your dependents have used this plan since January ?
	None 1 2-4 5-6 >6
2.	Please indicate the reason(s) for having utilized the plan?
	eye exams eyewear contact lenses
3.	How would you rate your experience with the Superior Vision plan with regard to claims processing, plan coverage, extent of network, customer service, etc ?
	a. Very Satisfied b. Somewhat Satisfied c. Somewhat Dissatisfied d. Very Dissatisfied
4.	If you answered "c" or "d" to the previous question, please indicate the nature of the problem(s) that you have experienced.
	Provider not in network Utilizing services at eyewear providers Coverage not as expected Claims not paid in timely manner Claims denied Customer Service was not helpful or "knowledgeable Other: Please explain in the Comments field below

5.	Approximately how much of your own time was spent on resolving the problems you experienced ?
	Less than 1/2 hour 1/2 to 1 hour 1 - 2 hours More than 2 hours
6.	How were the problems ultimately resolved ?
	Provider's office handled it. Assistance from Superior Vision Customer Service Line Assistance from HR Numerous calls and people involved (self, Customer Service, HR, etc.) Still unresolved
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DELTA DENTAL SURVEY

1.	What is the approximate total number of times that you and your dependents have used this plan since January ?
	None 1 2-4 5-6 >6
2.	Please indicate the reason(s) for having utilized the plan?
	routine checkups preventative care (filings, periodontal work, etc.) major care (crowns, inlays, onlays) orthodontic work for child under 19 orthodontic work for adult
3.	How would you rate your experience with the Delta Premier plan with regard to claims processing, plan coverage, extent of network, customer service, etc ?
	a. Very Satisfied b. Somewhat Satisfied c. Somewhat Dissatisfied d. Very Dissatisfied
4.	If you answered "c" or "d" to the previous question, please indicate the nature of the problem(s) that you have experienced.
	Provider not in network Utilizing services at eyewear providers Coverage not as expected Claims not paid in timely manner Claims denied Customer Service was not helpful or "knowledgeable Other: Please explain in the Comments field below

5.	Approximately how much of your own time was spent on resolving the problems you experienced ?
	Less than 1/2 hour 1/2 to 1 hour 1 - 2 hours More than 2 hours
6.	How were the problems ultimately resolved ?
	Provider's office handled it. Assistance from Delta Premier Customer Service Line Assistance from HR Numerous calls and people involved (self, Customer Service, HR, etc.) Still unresolved
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PRESCRIPTION DRUG SURVEY

1.	What is the approximate total number of times that you and your dependents have used this plan since January ?
	None 1-2 3-5 6-10 >10
2.	How would you rate your experience with the Merk Medco Prescription Drug Program with regards to claims processing, plan coverage, extent of network, customer service, etc ?
	a. Very Satisfied b. Somewhat Satisfied c. Somewhat Dissatisfied d. Very Dissatisfied
3.	If you answered "c" or "d" to the previous question, please indicate the nature of the problem(s) that you have experienced.
	Provider not in network Coverage not as expected 90 day prescription refills Claims denied Customer Service was not helpful or "knowledgeable Other: Please explain in the Comments field below

4.	Approximately how much of your own time was spent on resolving the problems you experienced ?
	Less than 1/2 hour 1/2 to 1 hour 1 - 2 hours More than 2 hours
5.	How were the problems ultimately resolved ?
	Provider's office handled it. Assistance from Prescription Drug Customer Service Line Assistance from HR Numerous calls and people involved (self, Customer Service, HR, etc.) Still unresolved
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FLEXIBLE SPENDING ACCOUNTS SURVEY

1.	To date, approximately how many claims have you submitted for reimbursement ?
	None 1-2 3-5 6 or more
2.	How would you rate your experience with the Flexible Spending plan with regard to claims processing, customer service, etc ?
	a. Very Satisfied b. Somewhat Satisfied c. Somewhat Dissatisfied d. Very Dissatisfied
3.	If you answered "c" or "d" to the previous question, please indicate the nature of the problem(s) that you have experienced.
	Never received informational packet and claims forms Problems with claims reimbursement Customer Service was not helpful or "knowledgeable Other: Please explain in the Comments field below

4.	Approximately how much of your own time was spent on resolving the problems you experienced ?
	Less than 1/2 hour 1/2 to 1 hour 1 - 2 hours More than 2 hours
5.	How were the problems ultimately resolved ?
	Provider's office handled it. Assistance from Benefits Concepts System's Customer Service Line Assistance from HR Numerous calls and people involved (self, Customer Service, HR, etc.) Still unresolved
	Send survey to AZ Human Resources. Clear all fields and start over.


BENEFITS CONNECTION LINE SURVEY

1.	Have you utilized the Benefits Connection Line (1-866-258-8522) since you enrolled ?
	Yes No
2.	Approximately how many times since January have you utilized this Service Center ?
	1 2-4 5-6 More than 6
3.	Please indicate the reason(s) for having called this line.
	Adding dependent Requesting new ID card Resolve a benefits issue Explore plan coverage Understand a process Other: Please explain in the Comments field below

4.	How would you rate your experience with the Benefits Connection Line with regards to benefits and process knowledge, customer service attitudes, follow-up, ability to direct you to more appropriate sources, etc.
	a. Very Satisfied b. Somewhat Satisfied c. Somewhat Dissatisfied d. Very Dissatisfied

5.	If you answered "c" or "d" to the previous question, please indicate the nature of the problem(s) that you have experienced.
	Difficulty reaching Benefits Connection Line Representative not knowledgeable Representative not customer service oriented Lack of follow up Problem not appropriate for this Service Center Other: Please explain in the Comments field below

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