Employment Status:
      Full Time
      Part Time (eligible for insurance)
      Part Time (NOT eligible for insurance)

Age:
      Under 30
      31-35
      36-40
      41-45
      46-50
      51-55
      56-60
      61+

Have you compared the current Cuesta (SISC) plan rates with the available CalPERS rates? (see links above for more information)
      No
      Yes

How many individuals in your household are on Cuesta’s (SISC) health insurance plan?
      1
      2
      3+

How many individuals in your household would be on Cuesta’s (SISC) health insurance plan if we went to a tiered system?
      1
      2
      3+

Are you interested in returning to the tiered health purchase system instead of the current composite rate?
      No
      Yes
      Maybe (explain)  

Does your partner have insurance available elsewhere?
      No
      Yes
      N/A

Which option are you currently on?
      Option A
      Option B
      Option C
      Option D
      None

Have you put off medical treatment or preventative care because you can no longer afford the co-pays and deductibles?
      No
      Yes

Have you or your dependents stopped or had to change medications because Cuesta’s (SISC) health insurance plan does not cover them?
      No
      Yes

Would you consider paying more than your current rate for a medical plan with an option to purchase retirement benefits for yourself upon retirement?
      No
      Yes

If you are covered, or could be covered by your spouses/ partner’s medical insurance plan, would you opt out of Cuesta’s (SISC) health insurance plan if you were to receive the fringe as an equivalent monetary amount?
      No
      Yes

Are you concerned about rising costs of premiums?
      No
      Yes

Do you find there is a lack of coverage in the current (SISC) health insurance plans?
      No
      Yes

Do you find there is a lack of available physicians your current (SISC) health insurance plan covers?
      No
      Yes

Are all your physicians currently covered by your existing SISC plan?
      No, none
      Yes, some
      Yes, all

Are you aware that SISC reduced their coverage to keep costs at the same rate as last year?
      No
      Yes

Other concerns / issues related to your existing SISC plan (600 char max):
     

I would be willing to pay more for medical insurance if I was provided improved coverage
      No
      Yes

I am NOT willing to pay more for medical insurance regardless of the coverage or plan
      No
      Yes

I am interested in the following CalPERS Medical Plans. CalPERS has both HMO and PPO options (select all that apply):
      Blue Shield Access - HMO
      PERSSelect - PPO
      PERSChoice - PPO
      PERSCare - PPO
      Comments regarding CalPERS:  

Any other comments regarding health insurance (600 char max):