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
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: ______