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Exit Survey
 
 
Respondent Name:  : 
Session Time: : 
Phone #:  : 
 
 
 
2. Hello, I’m __________ from __________. We are conducting a market research study and I would like to ask you a few questions. Please be assured that no one is trying to sell you anything and that no one will contact you as a result of your participation in this study.

To see if you qualify for the upcoming research study, there are a few questions I would like to ask you.
 
 
 
3. Gender (Check One Answer)
 
Male
 
Female
 
 
 
4. Which of the following categories best describes your age category? (Check One Answer)
 
Under 20
 
20 – 29
 
30 – 44
 
45 – 60
 
61 & Over
 
 
 
5. Note: The age will be used to screen the respondent for the presbyoptia (which usually appears after 40 years old).
 
 
6. Do you or anyone in your household, work for any of the following types of companies?
(Read list and record below)
YES NO
A marketing research firm or department
A manufacturer, distributor, or retailer of ophthalmic eyeglasses
A manufacturer, distributor, or retailer of pharmaceutical products
Or, an advertising agency or public relations firm
 
 
 
7. My client is interested in talking to some people who have participated in a market research study and to others who have not. When was the last time you participated in an interview, group discussion, opinion survey or product testing in which you were asked to rate or discuss products, ideas, or advertising?
 
Never
 
Within the last month
 
1- 3 months ago
 
3- 6 months ago
 
6 months ago or longer
 
 
 
8. Do you wear eyeglasses or contact lenses to correct your vision? Please select ‘yes’ if you wear eyeglasses or contact lenses rarely, sometimes or often.
 
Yes
 
No
 
 
 
9. Which of the following correction means do you wear…?
 
Eyeglasses only
 
Contact lenses only
 
Both eyeglasses and contact lenses
 
Readers Only
 
 
10. Please indicate to which extend do you wear each of the following:
Primarily wear Often but not primarily wear Sometimes wear Rarely or never wear
Eyeglasses
Contact lenses
 
 
 
11. How long have you been wearing glasses?
Months
Years
 
 
 
12. How many hours a day do you wear your eyeglasses? (Do Not Read List - Select One Response)
 
Less than 6 hours
 
6-8 hours
 
9 hours or more
 
 
 
13. Are you...
 
Myopic / nearsighted
 
Hyperopic / farsighted
 
Myopic & hyperoic / Nearsighted & farsighted
 
Presbyopic
 
Myopic & Presbyopic
 
Hyperopic & Presbyopic
 
I don’t know
 
 
 
14. Do you experience the following without your eyeglasses or contact lenses?


Blurred vision when looking at an object in the distance (e.g. looking at a landscape)

 
Yes
 
No
 
 
 
15. Blurred vision when looking at an object that is close up (e.g. reading a book)
 
Yes
 
No
 
 
 
16. This is not visible to the respondents. For data purpose
 
Good visual acuity in near / close vision
 
Good visual acuity in far / distance vision
 
TERMINATE
 
 
 
17. Some simple visual acuity tasks will be carried out just before the test to validate the consumers’ visual acuity (not necessary for the respondents wearing contact lenses for the test)
 
 
 
18. Transitions (Photochromic) lenses are clear lenses indoors that darken outdoors on exposure to sunlight. When not exposed to outdoor sunlight (for example by walking indoors), they will gradually return to their clear state.


Is your current pair of glasses clear or Transitions (photochromic) lenses?

 
Clear lenses
 
Photochromic or Transitions lenses (variable tint lenses, lenses which change color depending on sunlight)
 
Other Type
 
 
 
19. Would you be ready to wear Transitions (Photochromic) lenses?
 
I would certainly wear them
 
I would probably wear them
 
I would probably not wear them
 
I would never wear them
 
 
 
20. What kind of eyeglasses do you currently wear?
(Check One Answer)
 
Single vision lenses
These lenses require a prescription from an optometrist, an eye doctor or an ophthalmologist
 
Line Bifocal
These lenses provide correction for both far vision in the upper part and near vision in the lower part with a visible line on the lens
 
Progressive lenses (no-line Bifocal)
Corrective eyeglasses providing correction for all vision distances (near vision in the lower part, intermediate vision in the middle part and far vision in the upper part) with no visible line on the lens
 
Ready made or readers
These lenses do not require any prescription from an optometrist, an eye doctor or an ophthalmologist. They allow you to see near only
 
Specific lenses
i.e., reduce eye fatigue, for computer work, for driving etc...
 
Others
 
Don’t know

 
 
 
21. Note: presbyopia usually appears from 40 years old. There can be presbyoptics respondent younger than 45 years old.
 
 
 
22. How satisfied are you with the glasses you currently wear?
 
Very satisfied
 
Somewhat satisfied
 
Neither satisfied, nor dissatisfied
 
Somewhat dissatisfied
 
Very dissatisfied
 
 
 
23. Would you say your eyes are...
 
Very sensitive to light
 
Rather sensitive to light
 
Moderately sensitive to light
 
Rather not sensitive to light
 
Not sensitive at all to light
 
 
 
24. We would like to invite you to participate in a consumer test. Let me assure you that we are not trying to sell you anything, it is only your opinions that we are interested in. The test will last approximately two hours and will be held at: (Insert Location). During this test, you’ll have the opportunity to evaluate different lenses in indoor and outdoor environments.


To thank you for your participation, we would like to give you $XX.00 at the end of the test. Would you be interested in participating in one of these discussions?

 
Yes (schedule)
 
No
 
 
 
25. Are you available on: (Insert planning)