County ______
Community ______
Environmental Scan
Data Collection Form
Background Information
Please complete this form for each store observed.
Date:______Store Name:______
Area:______Team:______
Store Type (check one)
Chain Convenience Gas Station Pharmacy Small Market Supermarket
Other (please specify): ______
Street Address: ______
City:______State: ______
Is the store within 1,000 feet of a school?….. Yes No
Is the store within 1,000 feet of a church?….. Yes No
Is the store within 1,000 feet of a playground or recreational facility?….. Yes No
Is the store within 1,000 feet of a daycare center?….. Yes No
Other observations: ______
Environmental Scan
Data Collection Form - Tobacco
Outside Survey
Please complete this form for each store observed.
Standing outside the store, carefully look at the store’s visible walls, windows, outside areas, etc. Chances are there are lots of signs and advertising. There are several types of ads for cigarettes, smokeless tobacco and alcoholic beverage products you might see such as home-made signs, professionally produced posters or signs advertising specific brands, neon signs, small brand stickers on the door, or mini-billboards on the store’s property. Record the type and brands of the visible tobacco product ads below:
Marlboro / Camel / Winston / Kool / Newport / Others / Smokeless TobaccoStore-made signs or ads
Professional signs or ads
Other tobacco promotions or ads
Anti-smoking signs
Minimum-age notices “We Card”
Other Observations: ______
Environmental Scan
Data Collection Form - Alcohol
Outside Survey
Please complete this form for each store observed.
Standing outside the store, carefully look at the store’s visible walls, windows, outside areas, etc. Chances are there are lots of signs and advertising. There are several types of ads for cigarettes, smokeless tobacco and alcoholic beverage products you might see such as home-made signs, professionally produced posters or signs advertising specific brands, neon signs, small brand stickers on the door, or mini-billboards on the store’s property. Record the type and brands of the visible alcoholic beverage ads below:
Beer / Alcopops / Liquor / Malt Liquor / Wine / Wine Coolers / OthersStore-made signs or ads
Professional signs or ads
Other alcohol promotions or ads
Anti-drinking signs
Minimum-age notices “We Card”
Other Observations: ______
Environmental Scan
Data Collection Form-Tobacco
Quick Inside Survey
Please complete this form for each store observed.
Access to Tobacco Products
Cigarettes (check one):
Self-serve (located where customers can reach the cigarettes by themselves)
Behind the counter
In locked case, not behind counter
Other location requiring clerk assistance
Smokeless Tobacco (check one):
Self-serve (located where customers can reach the cigarettes by themselves)
Behind the counter
In locked case, not behind counter
Other location requiring clerk assistance
Other Tobacco Products (check one) ______(type)
Self-serve (located where customers can reach the cigarettes by themselves)
Behind the counter
In locked case, not behind counter
Other location requiring clerk assistance
Are cigarettes near candy displays……………………………….. Yes No
Are other tobacco products near candy displays…………………. Yes No
Are cigarettes where store clerks can easily see them? ………….. Yes No
Are other tobacco products where clerks can easily see them? ..… Yes No
Tobacco Ads Inside the Store
Are tobacco ads or signs located at three feet from the floor or below? …... Yes No
Are there any smoking prevention use ads or signs? ………………...…….. Yes No
Are there any signs informing customers that there is a minimum age to purchase
tobacco products, or that they don’t sell tobacco products to minors? …… Yes No
Environmental Scan
Data Collection Form-Alcohol
Quick Inside Survey
Please complete this form for each store observed.
Access to Alcohol Products
Beer (check one or more):
On the shelf
In a display at the front of the store
In a refrigerated area
Other location requiring clerk assistance
Wine Coolers (check one or more):
On the shelf
In a display at the front of the store
In a refrigerated area
Other location requiring clerk assistance
Other Alcohol Products (check one or more) ______(type)
On the shelf
In a display at the front of the store
In a refrigerated area
Other location requiring clerk assistance
Are alcohol products near candy displays……………………………….. Yes No
Are alcohol products cold (ready to consume)………..…………………. Yes No
Are alcohol products where store clerks can easily see them? ………….. Yes No
Alcohol Ads Inside the Store
Are alcohol ads or signs located at three feet from the floor or below? …... Yes No
Are there any alcohol use or abuse prevention ads or signs? ………….….. Yes No
Are there any signs informing customers that there is a minimum age to purchase
Alcohol products, or that they don’t sell alcohol products to minors? ….… Yes No