Copy of Counter Store Audit Center Survey

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Your Name: *

Date/time: *

YYYY

Time

Name of the store you are auditing: *

1. Can you survey the store? *Required *

Yes- continue

No, store does not exist [skip to Q37]

No, store closed [continue with Q2-Q5, then skip to Q37]

No, under 18 not allowed[continue with Q2-Q5, then skip to Q37]

No, members only[continue with Q2-Q5, then skip to Q37]

No, unsafe [skip to Q37]

No, other reason not listed [continue with Q2-Q5, then skip to Q37]

Required

2. Does the actual store name match the assigned store name?

Yes

Clear selection

If no above, enter the correct name:

3. Does the actual store address match the assigned store address?

Yes

Clear selection

If no above, enter the correct address:

4. Choose one best store type:

Convenience store with or without gas

Drug store or pharmacy

Beer, wine, or liquor store

Grocery Store

Mass merchandiser (Ex. Walmart)

Tobacco shop [Skip to Q37]

Hookah Lounge [Skip to Q37]

E-cigarette/Vape shop [Skip to Q37]

Other store type not listed

Clear selection

5. Which products are advertised anywhere outside of the store? These are ads on windows/doors facing out, buildings, sidewalks, gas pumps, or elsewhere.

5a. Cigarettes- Non-menthol

Yes

Clear selection

5b. Cigarettes- Menthol

Yes

Clear selection

5c. Cigarillos/little cigars/blunts

Yes

Clear selection

5d. Premium large cigars

Yes

Clear selection

5e. Chew, snuff, dip, snus

Yes

Clear selection

5f. E-cigarettes

Yes

Clear selection

6a. Is WIC accepted here? (might be on door, sticker, or on product)

Yes

Clear selection

6b. Is SNAP accepted here?

Yes

Clear selection

7. Are alcoholic beverages sold here?

Yes

No [Skip Q15-Q25]

Clear selection

8. Is a pharmacy counter present?

Yes

Clear selection

9. Is tobacco sold here? *

Yes

No [Skip to Q15]

10. Answer these questions about CIGARETTES

10a. Are any non-menthol OR menthol cigarettes sold here?

Yes

No [skip to Q11]

Clear selection

10b. Enter CHEAPEST single cigarette pack advertised price: XX.XX (do not enter $ sign)

10c. Are there any cigarette price promotions?

Yes

Clear selection

10d. Are menthol cigarettes SOLD here?

Yes

No [Skip to Q10h]

Clear selection

10e. Are NEWPORT MENTHOL cigarette single packs (regular hard pack) sold here?

Yes

Clear selection

10f. Enter NEWPORT MENTHOL cigarette single pack advertised price (regular hard pack):XX.XX (do not ever $ sign)

10g. Are there any menthol PRICE promotions?

Yes

Clear selection

10h. Are any non-menthol OR menthol cigarettes within 12" of YOUTH products?

Yes

Clear selection

10i. Are any non-menthol OR menthol cigarette ads within 3 feet of FLOOR?

Yes

Clear selection

11. Answer these questions about CIGARILLOS/LITTLE CIGARS/BLUNTS

11a. Are cigarillos, little cigars, OR blunts SOLD here?

Yes

No [Skip to Q12]

Clear selection

11b. Are FLAVORED cigarillos, little cigars, OR blunts SOLD here?

Yes

Clear selection

11c. Are SINGLE cigarillos, little cigars, OR blunts SOLD here?

Yes

Clear selection

11d. Are any cigarillos, little cigars, OR blunts advertised for LESS than $1?

Yes

Clear selection

11e. Are any cigarillos, little cigars, OR blunts placed within 12" of YOUTH products?

Yes

Clear selection

11f. Are any cigarillos, little cigars, OR blunts advertised within 3 feet of the FLOOR?

Yes

Clear selection

11g. Are ANY cigarillos, little cigars, OR blunts in SELF-SERVICE displays?

Yes

Clear selection

11h. Are there any cigarillos, little cigars, OR blunts PRICE promotions?

Yes

Clear selection

12. Answer these questions about PREMIUM LARGE CIGARS:

12a. Are premium large cigars SOLD here?

Yes

No [skip to Q13]

Clear selection

12b. Are FLAVORED premium large cigars sold here?

Yes

Clear selection

12c. Are any premium large cigars placed within 12" of YOUTH products?

Yes

Clear selection

12d. Are any premium large cigars advertised within 3 feet of FLOOR?

Yes

Clear selection

12e. Are ANY premium large cigars SELF-SERVICE displays?

Yes

Clear selection

13. Answer these questions about CHEW/SNUFF/DIP/SNUS:

13a. Is chew, snuff, dip, snus SOLD here?

Yes

Clear selection

13b. Are FLAVORED chew, snuff, dip, snus products sold here?

Yes

Clear selection

13c. Are any chew, snuff, dip, snus products placed within 12" of YOUTH products?

Yes

Clear selection

13d. Are any chew, snuff, dip, snus products advertised within 3 feet of FLOOR?

Yes

Clear selection

13e. Are there any chew, snuff, dip, snus PRICE promotions?

Yes

Clear selection

14. Answer these questions about E-CIGARETTES:

14a. Are e-cigarettes SOLD here?

Yes

Clear selection

14b. Are FLAVORED e-cigarettes sold here?

Yes

Clear selection

14c. Are any e-cigarettes placed within 12" of YOUTH products?

Yes

Clear selection

14d. Are any e-cigarettes advertised within 3 feet of FLOOR?

Yes

Clear selection

14e. Are ANY e-cigarettes in SELF SERVICE displays?

Yes

Clear selection

14f. Are there any e-cigarettes PRICE promotions?

Yes

Maybe

Clear selection

14g. Is BLU DISPOSABLE E-CIGARETTES MENTHOL (single) sold here?

Yes

No [skip to Q15]

Clear selection

14h. Enter BLU DISPOSABLE E-CIGARETTE MENTHOL (single) advertised price:XX.XX (do not enter $ sign)

15. Would you like to answer questions about alcohol during this visit?

Yes

Clear selection

16. Is beer sold here?

Yes

No [Skip to Q17]

Clear selection

If yes, are the following sizes present?

16a. 6 pack of 12oz cans?

Yes

Clear selection

16b. 12 pack of 12 oz cans

Yes

Clear selection

16c. 48 pack of 12 oz cans?

Yes

Clear selection

16d. 40 oz bottles?

Yes

Clear selection

17. Are flavored malt beverages sold here?

Yes

No [Skip to Q18]

Clear selection

If yes, indicate which types are present:

17a. Hard soda, water, or setlzer?

Yes

Clear selection

17.b Hard teas?

Yes

Clear selection

17c. Hard lemonades?

Yes

Clear selection

17d. "Pre-mixed cocktails" (Four Loko, Joose, Lime-a-Rita)?

Yes

Clear selection

18. Is malt liquor sold here(Colt45, Mickey's, Steel Reverse, Old English)

Yes

No [Skip to Q19]

Clear selection

If yes, are the following sizes present?

18a. 40 oz bottles?

Yes

Clear selection

18b. 12 oz 6 pack?

Yes

Clear selection

19. Are distilled spirits/liquor sold here (whiskey, vodka, tequila, rum, gin)?

Yes

No [Skip to Q20]

Clear selection

19a. Are single-serving bottles of distilled spirits/liquor sold here?

Yes

Clear selection

19b. Are multiple serving bottles of distilled spirits/liquor sold here?

Yes

Clear selection

19c. Are flavored distilled spirits/liquor sold here?

Yes

Clear selection

19d. Are natural or unflavored distilled spirits/liquor sold here?

Yes

Clear selection

20. Is wine sold here?

Yes

No [Skip to Q21]

Clear selection

If yes, are the following sizes present?

20a. Mini/single serving?

Yes

Clear selection

20b. 4 or 6 pack of single serving?

Yes

Clear selection

20c. 750mL (standard wine bottle)

Yes

Clear selection

21. Are non-alcohol beverages (soda, water, or fruit juice) placed in the cooler as alcoholic beverages?

Yes

No cooler

Clear selection

22. Are single serving cans of alcohol beverage available in the coolers? This includes mini's of wine or spirits plus canned beverages (Four Loko, Lime-a-Rita, etc.) that cannot be resealed regardless of their size.

Yes

Clear selection

23. Is alcohol placed on the endcaps of shelves or in free-standing displays/racks?

Yes

Clear selection

24. Is alcohol displayed within 12 inches of toys, candy, mints, or gum ?

Yes

Clear selection

25. Is alcohol displayed or advertised within 3 feet or less of the floor?

Yes

Clear selection

26. Would you like to answer questions about food and beverages during this visit?

Yes

Clear selection

27. Does the store have decals, signage, and/or advertisements posted outside the building for the following?

27a. WIC/WIC acceptance?

Yes

Clear selection

27b. FoodShare/EBT card acceptance?

Yes

Clear selection

27c. Fruits or Vegetables?

Yes

Clear selection

27d. Non-fat and low fat milk products?

Yes

Clear selection

27e. Soft drinks or other sweetened beverages?

Yes

Clear selection

27f. Chips or other salty snacks?

Yes

Clear selection

27g. Alcohol or alcoholic beverages?

Yes

Clear selection

28. Fresh or ready-to-go fruit available?

Yes

Clear selection

28a. Number of varieties of fresh fruit:

28b. Number of varieties of ready-to-eat fruit:

28c. Fresh or ready-to-eat fruit placement at eye level or other prominent places?

Yes

Clear selection

28d. Fresh or ready-to-eat fruit promotion, advertisement, decals, or signage such as shelf labeling or other point-of-purchase prompts?

Yes

Clear selection

28e. Fresh or ready-to-eat fruit near or within arm's reach at checkout area, counter, or aisle?

Yes

Clear selection

29. Fresh or ready-to-eat vegetables available?

Yes

No [Skip to Q30]

Clear selection

29a. Number of varieties of fresh vegetables:

29b. Number of varieties of ready-to-eat vegetables:

29c. Fresh or ready-to-eat vegetables placement at eye level or other prominent places?

Yes

Clear selection

29d. Fresh or ready-to-eat vegetable promotion, advertisement, decals, or signage such as shelf labeling or other point-of -purchase prompts?

Yes

Clear selection

29e. Fresh or ready-to-eat vegetable near or within arm's reach at checkout area, counter, or aisle?

Yes

Clear selection

30. Canned fruit or vegetables available?

Yes

No [Skip to Q31]

Clear selection

30a. Number of varieties of canned fruit:

30b. Number of varieties of canned vegetables:

30c. Canned fruit or vegetables placement at eye level or other prominent places?

Yes

Clear selection

30d. Canned fruit or vegetables promotion, advertisement, decals or signage such as shelf labeling or other point-of-purchase prompts?

Yes

Clear selection

31. Frozen fruit or vegetables available?

Yes

No [Skip to Q32]

Clear selection

31a. Number of varieties of frozen fruit:

31b. Number of varieties of frozen vegetables:

31c. Frozen fruit or vegetable placement at eye level or other prominent places?

Yes

Clear selection

31d. Frozen fruit or vegetable promotion, advertisement, decals or signage such as shelf labeling or other point-of-purchase prompts?

Yes

Clear selection

32. Dried fruit available?

Yes

No [Skip to Q33]

Clear selection

32a. Number of varieties of dried fruit:

32b. Dried fruit placement at eye level or other prominent places?

Yes

Clear selection

32c. Dried fruit promotion, advertisement, decals or signage such as shelf labeling or other point-of-purchase prompts?

Yes

Clear selection

32d. Dried fruit near or within arm's reach at checkout area, counter, or aisle?

Yes

Clear selection

33. Milk available?

Yes

Clear selection

33a. Largest size of reduced fat or fat free milk (skim, 1%, 2%) available?

No 1% or skim/fat free milk available

Less than 16oz

Pint (16 floz)

Quart (32 floz)

Half Gallon (64 floz)

Gallon (128 floz)

Clear selection

34. Healthier drink options (100% juice of water) available?

Yes

No [Skip to Q35]

Clear selection

34a. Largest size of 100% juice available in fl oz (e.g., 64 oz)? Enter "0" if unavailable.

34b. Largest size of water available in fl oz (e.g., 64 oz)? Enter "0" if unavailable.

35. Bread available?

Yes

No [Skip to Q36]

Clear selection

35a. 100% whole wheat/whole grain bread available?

Yes

Clear selection

36. Cereals available?

Yes

No [Skip to Q37]

Clear selection

36a. Whole gain cereals available? (Whole grain cereals=whole grain as the primary ingredient by weight AND meet labeling requirements for making a health claim as a "whole grain food with moderate fat content")

Yes

Clear selection

36b. Lower sugar cereals (<7g sugar/serving) available?

Yes

Clear selection

ALMOST DONE! ANY NOTES? (Leave blank if none)

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