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• <br />ON <br />SCTC 0�19 <br />Stats and Community Wal -co Control Research <br />Start time: <br />End time: <br />1. Date of visit: <br />2. Store ID: 3. Coder ID: <br />4. Store Name: Does the actual store name match the assigned store name? <br />❑1 Yes <br />0a No — Enter correct name: <br />5. Store Location: Does the actual store address match the assigned address? <br />❑, Yes <br />Oo No — Enter correct address: <br />6. Can you survey this store? (If not, then select an option below and STOP.] <br />❑1 Yes, I can <br />❑, No, store does not exist <br />❑3 No, store is closed <br />❑, No, membership or fee required to enter <br />05 No, environment unsafe for me <br />❑, No, asked to leave before completing the survey <br />❑, Other (specify): <br />7. Does this store sell vaping products? <br />❑1 Yes (Continue to question #8) <br />❑o No (Discontinue this survey) <br />STORE DEMOGRAPHICS <br />8. Is this store best categorized as a... <br />❑, Vapeshop <br />OZ Vape kiosk <br />❑3 Head shop with vaping products <br />O, Convenience store, pharmacy; beer/wine/liquor store; grocery store/supermarket; <br />mass merchandiser/discount store —> use STARS <br />❑5 Other: <br />9. Exterior sign stating policy regarding minors entering the store? <br />❑, Minimum age must be 18 or older to enter <br />❑Z Minimum age must be 19 or older to enter <br />❑3 Minimum age must be 21 or older to enter <br />❑o No minimum age posted to enter <br />10. Does the store sell... <br />a. Alcoholic beverages? <br />❑, Yes <br />❑Q No <br />b. Cannabis / Marijuana? <br />❑, Yes <br />Oa No <br />c. Whipped cream chargers or dispensers (used for whippets)? <br />❑, Yes <br />❑, No <br />d. Other psychoactive substances (e.g., kratom, K2"spice, synthetic cannabinoids such as <br />"herbal incense" or "Scooby Snax", salvia)? <br />❑, Yes <br />❑a No <br />TYPES OF PRODUCTS SOLD <br />11. Tobacco devices or products sold: <br />a. Cigarettes? <br />❑, Yes <br />❑o No <br />b. Cigarillos/Ilttle cigars? <br />01 Yes <br />0o No <br />c. Large Cigars? <br />❑, Yes <br />❑o No <br />d. Pipe or roll your own tobacco? <br />❑, Yes <br />❑o No <br />e. Smokeless tobacco products? <br />01 Yes <br />❑p No <br />f. Hookah pipes /Water pipes? <br />❑, Yes <br />❑o No <br />g. Shisha? <br />0, Yes <br />❑o No <br />