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1. Date of visit:
<br />2. Coder Name/ID:
<br />Start Time: End Time:
<br />3, Store Name/ID:
<br />El, Store name matches assigned name
<br />4. Store Address:
<br />F1, Actual address matches assigned address
<br />5
<br />FIELD NOTES
<br />❑ This retail environment provides a
<br />great photo opportunity.
<br />Can you survey this store? [If not, then select an option below and STOP.]
<br />❑, Yes, i can
<br />❑Z No, store does not exist
<br />1:13 No, store is closed
<br />❑4 No, under 18 not allowed to enter
<br />❑5 No, membership or fee required to enter
<br />❑6 No, environment unsafe for me
<br />❑7 No, asked to leave before completing the survey
<br />❑8 Other (specify):
<br />EXTERIOR
<br />Which products are advertised outside the store (on windows/doors, building,
<br />sidewalk or elsewhere)?
<br />Cigarettes - non -menthol
<br />❑ ,
<br />Yes
<br />El -a
<br />No
<br />b_ Cigarettes - menthol
<br />❑ ,
<br />Yes
<br />❑ r,
<br />No
<br />c. Cigarillos/little cigars
<br />❑ ,
<br />Yes
<br />❑ 0
<br />No
<br />d. Large cigars
<br />❑ ,
<br />Yes
<br />❑
<br />No
<br />e. Chew, moist or dry snuff, dip or snus
<br />❑ ,
<br />Yes
<br />❑
<br />No
<br />f. E -cigarettes
<br />❑ ,
<br />Yes
<br />❑ ,
<br />No
<br />INTERIOR
<br />7. Store Type: (Choose one)
<br />El Convenience store with or without gas (e.g., 7 -Eleven, Exxon, Wawa)
<br />❑ z Drug store/pharmacy (e.g., Walgreens, Rite Aid, Duane Reade)
<br />113 Beer, wine, or liquor store (e.g., ABC)
<br />❑4 Grocery store (e.g., small market/deli/produce market) or supermarket (e.g., Stop & Shop, Harris Teeter, Albertson's)
<br />El Mass merchandiser (e.g., WalMart, Costco, BYs, Sam's Club) or discount store (e.g., Dollar General, Family Dollar)
<br />1:16 Tobacco shop (e.g., Cigarettes Cheaper, cigar shops, hookah bars, e -cigarette shops, or other tobacco shops)
<br />❑ 7 Other (specify): (e.g., donut shop, bait & tackle)
<br />8. Any tobacco products sold here (i.e., cigarettes, cigars, cigarillos/little cigars, chew, moist or dry snuff, dip, snus, or e -cigarettes)?
<br />(Choose one)
<br />❑, Yes and visible to customers
<br />❑ a Yes but not visible to customers
<br />❑Q No [STOP if focusing on tobacco retailers]
<br />Does the store have a pharmacy counter?
<br />❑ l Yes ❑o No
<br />10. Alcoholic beverages sold here?
<br />❑ 1 Yes El. No
<br />11 Does store display a graphic health warning sign?
<br />❑ 1 Yes ❑o No
<br />SCT+C 0009
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