AVC Field Inspection Form

Date of Inspection: _________________ Inspector Name or ID #:____________________________________ AVC Field Inspection form Store Name: ______________________________________________________________________________________ Address: ___________________________________________________ Store #: ______________________ City: ___________________________________________________ State: _____ Zip: ______________________ Store Type: (circle one) Gas Station (including gas island of grocery store) Convenience Store Grocery Store Drugstore Other: ____________________________________________ Tobacco Displays (circle one) 1. Are tobacco products available for purchase? Yes No 2. Are all tobacco products displayed in a single area of the store? Yes No If NO, please provide a description or image: ____________________________________ 3. Are tobacco products available for purchase in vending machines? Yes No If YES, please provide a description or image: _____________________________________ 4. Can a customer pick up a tobacco product without the clerk’s assistance? Yes No If YES, please provide a description or image: _____________________________________ 5. Are cigarette papers, pipes or other tobacco paraphernalia accessible without the clerk’s assistance? Yes No If YES, please provide a description or image: _____________________________________ 6. Are cigarettes available in quantities less than a pack? Yes No (single sticks, two for a dollar, or similar) If YES, please provide a description or image: _____________________________________ Agency/Group: _____________________________________________________ Date of Inspection: _________________ Inspector Name or ID #:____________________________________ 7. Are tobacco ‘lookalike’ products offered for sale? Yes No (candy cigarettes, chocolate cigars, beef jerky or coffee “chew,” pouches of shredded bubble gum) If YES, please provide a description or image: _____________________________________ 8. Are free samples offered of any tobacco products? Yes No If YES, please provide a description or image: _____________________________________ Signage (circle one) 9. Are tobacco products or tobacco product advertising displayed within 2 feet of youth oriented products such as candy, toys, gum, etc.? Yes No If YES, please provide a description or image: _____________________________________ 10. Are all indoor tobacco signs and advertisements limited to brand name, logo and other trademarks, and price (Marlboro logo is chevron and Philip Morris lion/unicorn seal, Camel logo is camel silhouette, other images such as landscapes, phones, cars, unwrapped tobacco products, loose cigarettes, hands holding products are not logos or trademarks)? Yes No If NO, please provide a description or image: _____________________________________ 11. Are there video, audio, or other media advertisements for tobacco products, such as videos or scrolling messages at the gas pumps, videos on TV monitors inside the store, offers for mobile apps or mobile coupon redemption, videos on cash registers or on payments screens, etc.? Yes No If YES, please provide a description or image: _____________________________________ 12. Are tobacco advertisements located outside of the tobacco sales area? Yes No If YES, please provide a description or image: _____________________________________ 13. If the location is within 500 feet of a school or playground, are there any outdoor or outward-facing tobacco advertisements? Yes No If YES, please provide a description or image: _____________________________________ 14. Are there outdoor advertisements for tobacco products that exceed 14 square feet, including a mosaic of multiple tobacco advertisements? Yes No If YES, please provide a description or image: _____________________________________ Agency/Group: _____________________________________________________ Date of Inspection: _________________ Inspector Name or ID #:____________________________________ 15. Are signs near the register stating that security cameras are used to detect underage sales? Yes No 16. Is there a sign on or near the entrance door that says: (circle one) We Card Under 40 We Card Under 35 We Card Under 30 We Card Under 27 We Card Under 18 We Card None 17. Is there a sign on the tobacco display that says: (circle one) We Card Under 40 We Card Under 35 We Card Under 30 We Card Under 27 We Card Under 18 We Card None 18. Is there a sign in the employee break room that says: (circle one) We Card Under 40 We Card Under 35 We Card Under 30 We Card Under 27 We Card Under 18 We Card None 19. Are there age-of-sale reminders, calendars, stickers, or similar near every register? Yes No Electronic Cigarettes and Related Products (circle one) 20. Are there signs displayed stating that identification is required for purchases of electronic cigarettes and related products? Yes No If YES, under what age is identification required: _____________________________________ 21. Are electronic cigarettes accessible to the public without clerk assistance? Yes No 22. Are electronic cigarette accessories (such as e-liquid in cartridges or bottles, specialized batteries or chargers, mouthpieces, atomizers, etc.) accessible to the public without clerk assistance? Yes No 23. Do any signs or advertisements for electronic cigarettes or related products contain elements beyond brand name, logo, and price? Yes No If YES, please provide a description or image: _____________________________________ Additional Comments: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Agency/Group: _____________________________________________________ Date of Inspection: _________________ Inspector Name or ID #:____________________________________ AVC Location (circle one) Albertson’s Foods Co. Safeway AMOCO Food 4 Less Sam’s Club AM/PM Fred Meyer Scott’s ARCO Gerbes Shell Baker’s Hilander Shamrock Beacon Jay C Smith’s BP King Soopers Smith’s Express Caltex Kroger 7-Eleven Chevron Kwik Shop 76 Circle K Loaf n Jug Texaco CityMarket Mac’s Convenience Stores Tom Thumb Conoco Marketside Turkey Hill Conoco-Philips Mobil Ultramar Corner Store Owen’s Union 76 CST Pak n’ Save Valero CVS Pavilions Vons Diamond Shamrock PayLess Super Markets Walgreens Dillion’s Phillips 66 Walmart Esso QFC Wal-Mart Exxon Quik Stop Wal-Mart Neighborhood Market Fry’s Ralph’s Fry’s Marketplace Rite Aid Agency/Group: _____________________________________________________ .

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