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1, Date of visit: _______ StartTime: ___ _ End TIme:
<br />2. Coder Nam e/ID: _____________________ _
<br />3. Store Name/ID: _____________________ _
<br />This retail environment provides a
<br />great photo opportunity.
<br />0, Store name matches assigned name
<br />4. Store Address:
<br />0, Actual address matches assigned address
<br />S. Can you survey this store? [If not, then select an option below and STOP.]
<br />0, Yes,lcan
<br />O 2 No, store does not exist
<br />OJ No, store is closed
<br />0 4 No, under 18 not allowed to enter
<br />05 No, membership or fee required to enter
<br />0 6 No, environment unsafe for me
<br />0 7 No, asked to leave before completing the survey
<br />0
<br />8
<br />Other (specify): __________________ _
<br />EXTERIOR
<br />6. Which products are advertised outside the store (on windows/doors, building,
<br />sidewalk or elsewhere)?
<br />a . Cigarettes -non-menthol
<br />b. Cigarettes -menthol
<br />c. Cigarillos/little cigars
<br />d. Large cigars
<br />e . Chew, moist or dry snuff, dip or snus
<br />f. E-ciga rettes
<br />INTERIOR
<br />7. Store Type: (Choose one)
<br />0, Convenience store with or without gas (e.g., 7-Eleven, Exxon, Wawa)
<br />O 2 Drug store/pharmacy (e.g., Walgreens, Rite Aid, Duane Reade)
<br />OJ Beer, wine, or liquor store (e.g., ABC)
<br />0 1
<br />0 ,
<br />0 ,
<br />0 ,
<br />0 ,
<br />0
<br />1
<br />Yes Do No
<br />Yes Do No
<br />Yes Do No
<br />Yes Do No
<br />Yes Do No
<br />Yes 0 No 0
<br />0 4 Grocery store (e.g., small market/deli/produce market) or supermarket (e.g., Stop & Shop, Harris Teeter, Albertson's)
<br />05 Mass merchandiser (e.g., WalMart, Costco, BJ's, Sam's Club) or discount store (e.g., Dollar General, Family Dollar)
<br />0 6 Tobacco shop (e.g., Cigarettes Cheaper, cigar shops, hookah bars, e-cigarette shops, or other tobacco shops)
<br />0 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 />0, Yes and visible to customers
<br />O 2 Yes but not visible to customers
<br />Do No [STOP if focusing on tobacco retailers]
<br />9. Does the store have a pharmacy counter?
<br />0, Yes Do No
<br />, o. Alcoholic beverages sold here?
<br />0 1 Yes Do No
<br />, ,. Does store display a graphic health warning sign?
<br />0, Yes Do No
<br />• " SCTC ."'~.
<br />V(>r ~I O I1 1 () (051021 14 )
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