Alcohol Outlet Observation Form

Name of Observer: Date and Time of Observation:

Store Name:                                                                       Hours of Operation: Store Address: Outside the Store (Circle Yes or No) Is the store located in a residential community?             Yes   or    No Is a school located within three blocks of the store?       Yes   or    No Is there evidence of public drinking or substance use?     Yes   or    No If yes, describe: Describe the alcohol and tobacco advertising located outside of the store: Inside the Store (Circle Yes or No) Describe the alcohol and tobacco advertising located inside the store: Is the alcohol or tobacco advertising within 5 feet of candy?    Yes   or    No Is the alcohol and or the tobacco advertising within 3 feet of the floor?       Yes   or    No Are their non-alcohol products in the same refrigerator or refrigerators next to the alcohol?     Yes   or    No Circle the number of brands of malt liquors:         1-10     10-20     20-30 Circle the number of brands of wines:                 1-10    10-20     20-30 Circle the number of brands of Beers:                 1-10    10-20     20-30 Is alcohol education available in the store?          Yes   or    No If yes, describe: Are cigarettes sold?                   Yes   or    No Are there cigarette vending machines in the store?    Yes   or    No Are cigarettes behind the counter?                Yes   or    No