Illinois PRC NOPREN FOOD STORE OBSERVATION FORM 2015 … · Supermarket (Jewel-Osco, Mariano’s, Safeway) 1 a. Bank 0 1 Grocery (Aldi, Trader Joe’s, Save A Lot, “mom & pop”)

1

Illinois PRC NOPREN ▪ FOOD STORE OBSERVATION FORM ▪ 2015 (Adapted from BTGCOMP) BUSINESS ID :

BUSINESS NAME:

ADDRESS: BUSINESS ID: - -

DATE - -2015 STAFF 1 STAFF 2

START TIME : am/pm END TIME : am/pm

DISPOSITION CODE

Temporarily not accessible / Outside business hours 1

COMPLETION CODE Not safe 2 COMPLETED 01 Asked to leave / Observation not allowed by staff 3

PARTIALLY COMPLETED – CODE DISPOSITION 02 Does not meet study criteria – DESCRIBE IN NOTES 4 NOT STARTED – CODE DISPOSITION 03 Other (SPECIFY): 5 NOT ELIGIBLE – CODE DISPOSITION 96 NOTES:

A. GENERAL AND CHECK-OUT A1. TYPE OF STORE A6. Does the store have a…? NO YES Supermarket (Jewel-Osco, Mariano’s, Safeway) 1 a. Bank 0 1

Grocery (Aldi, Trader Joe’s, Save A Lot, “mom & pop”) 2 b. Pharmacy 0 1 Limited Service CODE A1a 3 c. Butcher or fresh meat service counter 0 1 A1a. TYPE OF LIMITED SERVICE – CODE ONLY IF A1=3 d. Deli counter 0 1

Convenience Store (7-11, White Hen) 1 e. Bakery 0 1 Small Discount Store (Dollar General, Dollar Tree) 2 A7. Is there plexiglass or other divider at the

cash register? NO YES

Drug Store/Pharmacy (CVS, Walgreens) 3 0 1 Liquor Store (Ryan’s Liquor, Binny’s Beverage Depot) 4 A8. Is there a security mirror or camera? 0 1

Other, SPECIFY: 5 A9. Is there fast food or other individual, ready-to eat items available

NO YES

A2. Number of cash registers (IF 10+, CODE 10) a. Salads/salad bar 0 1

A3. Does the store accept EBT/LINK/SNAP? NO YES b. Sandwiches (cold) 0 1 0 1 c. Pizza 0 1

A4. Does the store accept WIC? N/A No YES d. Hot dogs/corn dogs/hamburgers 0 1

9 0 1 e. Mexican (tacos, burritos, taquitos, etc.) 0 1 A5. Are these available at CHECK- OUT?

1. Self-Serve 2. Clerk Assisted f. Fried chicken 0 1

NO YES NO YES

a. Fresh fruits 0 1 0 1 g. Other hot, prepared food 0 1 b. Fresh vegetables 0 1 0 1 A10. Does the store have any seating for

food consumption? NO YES

c. Milk, unflavored 0 1 0 1 0 1 d. Soda, regular 0 1 0 1 T. TOBACCO/ALCOHOL e. Soda, diet 0 1 0 1 T1. Does the store sell any over-the-counter

Nicotine Replacement Products? (e.g., Nicorette gum, Commit lozenges, Nicoderm)

NO YES

f. Other sweetened beverage 0 1 0 1 0 1 g. Bottled water, plain 0 1 0 1 T2. Does the store sell any tobacco

products? 0 1 h. Salty snacks 0 1 0 1 i. Candy 0 1 0 1 T3. Is 50% or more of the store’s inventory

beer, wine, and/or liquor? 0 1 j. Sweetened baked goods 0 1 0 1

2

B. FRESH PRODUCE MARK “X” IF NONE AVAILABLE AND SKIP SECTION B

IF B1= NO, SKIP B2-B7

B1. AVAILABLE B2. TYPE

IF None, SKIP B3-B7 B3. QUALITY B4.

QTY B5. UNIT

IF None, SKIP B6-B7

B6. CURRENT PRICE

IF 77.77 (DK), SKIP B7

B7. PRICE TYPE

NO YES POOR* OK REG SPECIAL

a. Apples

0

1

Red Delicious 1

1 2

Pound 1

$ . Loose? N/Y

1 2 Granny Smith 2 Piece 2

None of above 8 None of above 8

b. Bananas

0

1

Regular yellow 1

1 2

Pound 1

$ . Loose? N/Y

1 2 None of above 8 Piece 2

None of above 8

c. Oranges

0

1

Navel 1

1 2

Pound 1

$ . Loose? N/Y

1 2 Valencia 2 Piece 2


d. Grapes

0

1

Red Seedless 1

1 2

Pound 1

$ . Loose? N/Y

1 2 Green 2 Bunch 2


e. Watermelon

0

1

Regular 1

1 2

Pound 1

$ .

1 2 Seedless 2 Piece 2


f. Avocado

0

1

Hass 1

1 2

Pound 1

$ . Loose? N/Y

1 2 Fuerte 2 Piece 2


g. Carrots

0

1

Full-sized 1

1 2

Pound 1

$ . Loose? N/Y

1 2 Baby-sized 2 Bunch 2


h. Tomatoes

0

1

Regular slicing 1

1 2

Pound 1

$ . Loose? N/Y

1 2 Roma 2 Piece 2


i. Broccoli

0

1

Bunch 1

1 2

Pound 1

$ . Loose? N/Y

1 2 Crown 2 Bunch 2


j. Lettuce

0

1

Iceberg 1

1 2

Pound 1

$ . Loose? N/Y

1 2 Romaine 2 Head 2


k. Bell pepper

0

1

Green 1

1 2

Pound 1

$ . Loose? N/Y

1 2 Red 2 Piece 2


* ≥ 25% of product batch is poor quality

3

- -

IF B1= NO, SKIP B2-B7

B1. AVAILABLE B2. TYPE

IF None, SKIP B3-B7 B3. QUALITY B4.

QTY B5. UNIT

IF None, SKIP B6-B7

B6. CURRENT PRICE

IF 77.77 (DK), SKIP B7

B7. PRICE TYPE

NO YES POOR* OK REG SPECIAL

l. Celery

0

1 Least Expensive 1 2

Pound 1

$ . Loose? N/Y

1 2 Bunch 2

None of above 8

m. Sweet potato

0


Pound 1

$ . Loose? N/Y

1 2 Piece 2

None of above 8

n. Spinach

0

1

Regular 1

1 2

Pound 1

$ . Loose? N/Y

1 2 Baby 2 Bunch 2


o. Greens

0

1

Collard 1

1 2

Pound 1

$ . Loose? N/Y

1 2 Turnip 2

Bunch 2 Mustard 3


p. Cabbage

0

1

Green 1

1 2

Pound 1

$ .

1 2 Red 2 Head 2


q. Chard

0


Pound 1

$ . Loose? N/Y

1 2 Bunch 2

None of above 8

r. Okra

0

1 Least Expensive 1 2 Pound 1

$ . Loose? N/Y

1 2

s. Beets 0 1 Least Expensive 1 2

Pound 1

$ . Loose? N/Y

1 2 Bunch 2

None of above 8

t. Corn

0


Pound 1

$ . Loose? N/Y

1 2 Piece 2

None of above 8

B8. Total number of Fresh Fruit options (IF 20+, CODE 20)

B9. Total number of Fresh Vegetable options (IF 20+, CODE 20)

B10. Are there any Fresh Fruits on sale? NO YES 0 1

B11. Are there any Fresh Vegetables on sale? NO YES 0 1

NOTES

* ≥ 25% of product batch is poor quality

4

D. DAIRY, EGGS and MEAT IF D1= NO, SKIP D2-D6

D1. AVAILABLE D2. BRAND

D3. QTY

D4. PACKAGE SIZE IF None SKIP D5-D6

D5. CURRENT PRICE IF 77.77 (DK), SKIP D6

D6. PRICE TYPE NO YES REG SPECIAL

a. Milk, whole (vitamin D), unflavored

0 1 Least Expensive

Gallon 1

$ . Asked? N/Y

1 2 ½ Gallon 2

None of above 8

b. Milk, 2% fat, unflavored

0 1 Least

Expensive

Gallon 1

$ . Asked? N/Y

1 2 ½ Gallon 2

None of above 8

c. Milk, 1% fat, unflavored

0 1 Least

Expensive

Gallon 1

$ . Asked? N/Y

1 2 ½ Gallon 2

None of above 8

d. Milk, skim (fat free), unflavored

0 1 Least

Expensive

Gallon 1

$ . Asked? N/Y

1 2 ½ Gallon 2

None of above 8

e. Lactose-free Milk, whole, unflavored

0 1 (Do not include milk made from soy, almond, rice or other non-dairy milk)

f. Lactose-free Milk, 2% fat, 1% fat or fat free, unflavored

0 1 (Do not include milk made from soy, almond, rice or other non-dairy milk)

D7. Is there any Unflavored Dairy Milk on sale? NO YES 0 1

g. Yogurt , whole, plain 0 1 (Do not include yogurt made from soy, almond, rice or other non-dairy milk)

h. Yogurt , Low-fat or Nonfat, plain

0 1 (Do not include yogurt made from soy, almond, rice or other non-dairy milk)

i. Yogurt , Low-fat, flavored

0 1 (Do not include yogurt made from soy, almond, rice or other non-dairy milk)

C. FROZEN FRUIT and VEGETABLES MARK “X” IF NONE AVAILABLE AND SKIP SECTION C

IF C1= NO, SKIP C2-C6

C1. AVAILABLE C2. BRAND IF None, SKIP C3-C6

C3. QTY

C4. PACKAGE SIZE IF None, SKIP C5-C6

C5. CURRENT PRICE IF 77.77 (DK), SKIP C6

C6. PRICE TYPE NO YES REG SPECIAL

a. Frozen Green Beans w/o added sauce

0

1

Birds Eye 1

12 oz 1

$ . 1 2

Pictsweet 2 16 oz 2

Green Giant 3 28 oz 3


b. Frozen Corn w/o added sauce

0 1

Birds Eye 1

12 oz 1

$ . 1 2 Pictsweet 2 16 oz 2

Green Giant 3 28 oz 3


C7. Total number of Frozen Fruit options (IF 10+, CODE 10)

C8. Total number of Frozen Vegetable options (IF 10+, CODE 10)

5

- - IF D1= NO, SKIP D2-D6

D1. AVAILABLE D2. BRAND

D3. QTY

D4. PACKAGE SIZE IF None SKIP D5-D6


D6. PRICE TYPE NO YES REG SPECIAL

j. Eggs 0 1 Least

Expensive

Dozen 1

$ .

1 2 ½ Dozen 2

None of above 8

k. Cheese, regular fat 0 1 (Sliced, shredded or block cheese, any flavor – Do not include cottage cheese, cream cheese, soy cheese, imitation cheese, or pasteurized process cheese products) l. Cheese, low or

reduced fat 0 1

IF D1= NO, SKIP D2-D6

D1. AVAILABLE D2.FAT

CONTENT/ BRAND

D3. QTY

D4. UNIT IF None SKIP D5-D6


D6. PRICE TYPE

NO YES

REG SPECIAL

m. Ground Beef, regular

(≥20% fat) 0 1

% fat

Pound 1

$ . 1 2 % lean None of above 8

IF DK, SPECIFY CUT:

n. Ground Beef, extra lean

(≤10% fat) 0 1

% fat

Pound 1

$ . 1 2 % lean None of above 8

IF DK, SPECIFY CUT:

o. Chicken, white meat (breast)

0 1 Least Expensive

Pound 1

$ . 1 2

None of above 8

p. Chicken, dark meat (thigh, leg, wings)

0 1 Least Expensive

Pound 1

$ . 1 2

None of above 8

q. Pork 0 1 (Do not include frozen pork)

r. Turkey 0 1 (Do not include frozen turkey)

s. Seafood/fish 0 1 (Do not include frozen seafood/fish)

t. Processed meats 0 1 Processed meats include hot dogs, bacon, ham, bologna, cold cuts, etc.

u. Any Fresh Meat 0 1 (Fresh beef, pork, chicken, turkey, lamb, etc. – Do not include fresh or frozen fish, frozen meats or processed meats like hot dogs, bacon, ham, bologna, or other cold cuts)

NOTES

Ground Beef, regular includes ground chuck, hamburger, ground beef; Ground Beef, extra lean includes ground round, ground sirloin

6

E. GRAINS AND DRIED BEANS

IF E1= NO, SKIP E2-E6

E1. AVAILABLE E2. BRAND

IF None, SKIP E3-E6

E3. QTY

E4. PACKAGE SIZE IF None, SKIP E5-E6

E5. CURRENT PRICE IF 77.77 (DK), SKIP E6

E6. PRICE TYPE

NO YES NO REG SPECIAL

a. Cereal, higher sugar content (≥ 6g sugar/svg)

0 1

Frosted Flakes

1

17 - 19 oz 1

$ . 1 2

Honey Nut Cheerios

2 14 - 15 oz 2

Honey Bunches of Oats

3 7 - 9 oz 3


b. Cereal, lower sugar content (< 6g sugar/svg)

0 1

Cheerios, plain

1

17 - 19 oz 1

$ . 1 2

Corn Flakes 2 14 - 15 oz 2

Rice Krispies 3 7 - 9 oz 3


c. Any low- sugar, high-fiber cereal

0 1 (e.g., Wheaties, Total, Shredded Wheat, Grape Nuts, Bran Flakes, Weetabix, Fiber One, Wheat or Multi-Grain Chex, Barbara’s Puffins, Uncle Sam’s or others with < 6g sugar and ≥ 3g fiber/serving)

d. Bread, white 0 1 Least Expensive

20 oz 1

$ . 1 2 16 oz 2

None of above 8

e. Bread, 100% whole wheat

0 1 Least Expensive 20 oz 1

$ . 1 2 16 oz 2

None of above 8

f. Rice, White 0 1 g. Rice, Brown 0 1 h. Pinto Beans, dried 0 1 i. Kidney Beans,

dried 0 1

j. Black-eyed Peas, dried

0 1

F. CANNED PRODUCTS

IF F1= NO, SKIP F2-F6

F1. AVAILABLE F2. BRAND

IF None, SKIP F3-F6

F3. QTY

F4. PACKAGE SIZE IF None, SKIP F5-F6

F5. CURRENT PRICE IF 77.77 (DK), SKIP F6

F6. PRICE TYPE

NO YES REG SPECIAL

a. Tomatoes, canned

0 1

Hunt’s 1

14.5 oz, Diced 1

$ . 1 2 Del Monte 2 28 oz, Diced 2

None of above

8 None of above 8

b. Green Beans, canned 0 1

Del Monte 1

14 - 15 oz 1

$ . 1 2 Green Giant 2 None of above 8

None of above

8

c. Pinto Beans, canned 0 1

7

- -

d. Kidney Beans, canned 0 1

e. Black-eyed Peas, canned

0 1

f. Any canned beans w/o added fat or sauce

0 1 (Kidney, black, navy, pinto, black-eyed, garbanzo etc.)

F7. Total number of Canned Fruit options (IF 10+, CODE 10)

F8. Total number of Canned Vegetable options (IF 10+, CODE 10)

F9. Are there any canned fruits w/o added sugar? NO YES 0 1

F10. Are there any canned vegetables w/o added salt? NO YES 0 1

G. SNACKS

IF G1= NO, SKIP G2-G6

G1. AVAILABLE G2. BRAND IF None, SKIP G3-G6

G3. QTY

G4. PACKAGE SIZE IF None, SKIP G5-G6

G5. CURRENT PRICE IF 77.77 (DK), SKIP G6

G6. PRICE TYPE

NO YES REG SPECIAL

a. Potato Chips, regular, salted (<3 oz)

0 1 Lay’s 1

1.00 - 1.25 oz 1

$ .

1 2 Ruffles 2 2.50 - 2.88 oz 2


b. Potato Chips, regular, salted (≥3 oz)

0 1 Lay’s 1

10 - 11 oz 1

$ .

1 2 Ruffles 2 7.00 oz 2


c. Hot or Spicy Chips

(or equivalent, <3 oz) 0 1

Cheetos 1

1.00 - 1.25 oz 1

$ .

1 2 None of above 8

2.35 - 2.40 oz 2 None of above 8

d. Hot or Spicy Chips

(or equivalent, ≥3 oz) 0 1

Cheetos 1

8.50 - 9.75 oz 1

$ .

1 2 None of above 8

3.25 - 3.75 oz 2 None of above 8

e. Baked or low-fat potato chips

0 1 (Less than 4 grams of fat per 1 oz serving)

f. Snack Cakes (Ho Hos, Cupcakes or

Swiss Rolls) 0 1

Hostess 1

2 - 3.5 oz 1

$ . 1 2 Little Debbie 2 13 - 15 oz 2


g. Cookies 0 1

Oreos 1

18 - 19 oz 1

$ .

1 2 Chips Ahoy 2 14 - 16.6 oz 2

None of above 8 5 - 6 oz 3

None of above 8

h. Candy 0 1

M&Ms, plain 1

1.5 - 1.75 oz 1

$ .

1 2 Hershey bar 2 2 - 2.5 oz 2

Snickers 3 3 - 3.5 oz 3


G7. Are there any Salty Snacks on sale? NO YES 0 1

G8. Is there any Candy on sale? 0 1 G9. Are there any Sweetened Baked Goods on sale? 0 1

Fractions for Potato Chips: 1/8 = 0.125; 3/8 = 0.375; 5/8 = 0.625; 7/8 = 0.875

8

H. BEVERAGES

IF H1= NO, SKIP H2-H6

H1. AVAILABLE

H2. BRAND IF None, SKIP H3-H6

H3. QTY

H4. PACKAGE SIZE IF None, SKIP H5-H6

H5. CURRENT PRICE

IF 77.77 (DK), SKIP H6 H6. PRICE TYPE

NO YES REG SPECIAL

a. Orange Juice, 100% juice

0 1

Minute Maid 1

15.2 oz 1

$ . 1 2 Tropicana 2 12 oz 2

None of above

8 None of above 8

b. Juice Drink, <50% juice

0 1

Minute Maid 1

15.2 oz 1


None of above

8 None of above 8

c. Fruit Punch 0 1

Pure Delite 1

16 oz 1

$ . 1 2 Little Hug 2 8 oz 2 None of above

8 None of above 8

d. Soda, regular 0 1

Coca-Cola 1

20 oz 1

$ . Asked? N/Y

1 2 Pepsi 2 12 oz 2

None of above 8 None of

above 8

e. Soda, diet 0 1

Coca-Cola 1

20 oz 1

$ . Asked? N/Y

1 2 Pepsi 2 12 oz 2


above 8

f. Energy Drink, regular

0 1

Red Bull 1

8-8.5 oz 1

$ . 1 2 Monster 2 16 oz 2

Rockstar 3 None of above 8

None of above 8

g. Isotonic Sports Drink, regular

0 1

Gatorade 1

20 oz 1

$ . 1 2 Powerade 2 32 oz 2


above 8

h. Enhanced Water, regular

0 1

Vitamin Water 1

20 oz 1

$ . 1 2 Propel 2 16-17 oz 2

Sobe Life 3 None of above 8

None of above 8

i. Bottled Water, plain

0 1 Dasani 1

20 oz 1

$ . Asked N/Y

1 2 Aquafina 2 24 oz 2


above 8

j. Sweetened Tea, regular

0 1 AriZona 1

23 oz 1

$ . 1 2 Gold Peak 2 16.9-18.5 oz 2


above 8

INDI

VIDU

AL S

IZE

(<1

lite

r/33

.8 fl

oz)

9

- -

IF H1= NO, SKIP H2-H6

H1. AVAILABLE

H2. BRAND IF None, SKIP H3-H6

H3. QTY

H4. PACKAGE SIZE IF None, SKIP H5-H6

H5. CURRENT PRICE

IF 77.77 (DK), SKIP H6 H6. PRICE TYPE

NO YES REG SPECIAL

k. Orange Juice, 100% juice

0 1

Minute Maid 1

59 - 64 oz 1



above 8

l. Juice Drink, <50% juice

0 1 Minute Maid 1

59 - 64 oz 1

$ . 1 2 Tropicana 2 128 oz 2 None of above 8 None of

above 8

m. Fruit Punch 0 1 Least Expensive

Gallon 1

$ . 1 2 ½ Gallon 2 None of above 8

n. Soda, regular 0 1 Coca-Cola 1

2 Liter 1

$ . Asked? N/Y

1 2 Pepsi 2 12 can case 2 None of above 8 None of

above 8

o. Soda, diet 0 1 Coca-Cola 1

2 Liter 1

$ . Asked? N/Y

1 2 Pepsi 2 12 can case 2 None of above 8 None of

above 8

p. Soda, least expensive regular cola

IF NO SODA AVAILABLE, SKIP ROW

2 Liter 1 $ .

Asked? N/Y 1 2 12 can case 2

None of above 8

q. Sweetened Tea, regular

0 1 AriZona 1

128 oz 1

$ . 1 2 Gold Peak 2 59 - 64 oz 2


H7. Is there any Regular Soda on sale? NO YES

0 1

H8. Is there any Diet Soda on sale? 0 1

H9. Is there any Other Sweetened Beverage on sale? 0 1

H10. Is there any Bottled Water on sale? 0 1

FAM

ILY

SI

ZE (

10

I. SNAP Provisions

COUNT THE NUMBER OF… I1. Fresh or Frozen (Perishable) Fruit options Bananas Frozen Pineapple Frozen Raspberries Apples Frozen Strawberries Mix (Fresh Fruit Salad) Oranges Frozen Blueberries Other:

(IF 7+, CODE 07)

I2. Canned or Shelf-Stable (Non-Perishable) Fruit options Canned Peaches Canned Mix (Fruit Cocktail, Tropical Blend Fruit Cups) Canned Pineapple Apple Sauce Canned Pears Cranberry Sauce Other:

(IF 7+, CODE 07)

I3. Fresh or Frozen (Perishable) Vegetable options Lettuce Sweet Potatoes Frozen Corn Tomatoes Bell Pepper Frozen Green Beans White Potatoes Onions Mix (Frozen Mixed Veggies, Bagged Salad) Other:

(IF 7+, CODE 07)

I4. Canned or Shelf-Stable (Non-Perishable) Vegetable options Canned Tomatoes Canned Collard Greens Canned Yams or Sweet Potatoes Canned Corn Canned Mushrooms Canned Mix (Mixed Veggies/Greens) Canned Green Beans Canned White Potatoes Other:

(IF 7+, CODE 07)

I5. Fresh or Frozen (Perishable) Meat, Poultry and Seafood options (Including Eggs) Eggs Bologna Tilapia Bacon Chicken Salmon Sausage Beef Hotdogs Other:

(IF 7+, CODE 07)

I6. Canned or Shelf-Stable (Non-Perishable) Meat, Poultry and Seafood options Canned Tuna Canned Vienna Sausages Canned Corn Beef Canned Chicken Canned Sardines Canned Spam Canned Fish Steaks Canned Crab Other:

(IF 7+, CODE 07)

I7. Fresh or Frozen (Perishable) Bread options Bread Bagels Biscuits Buns (Hotdog or Hamburger) English Muffins Croissants Other:

(IF 7+, CODE 07)

I8. Shelf-Stable (Non-Perishable) Bread options Bread Crumbs/Breading Breadsticks Croutons Other:

(IF 7+, CODE 07)

I9. Cereal options Cereal Cream of Wheat Oatmeal Grits Other:

(IF 7+, CODE 07)

I10. Fresh (Perishable) Dairy options Milk Cheese Butter Yogurt Sour Cream Other:

(IF 7+, CODE 07)

I11. Canned or Shelf-Stable (Non-Perishable) Dairy options Canned Milk (Evaporated or Condensed) Other:

(IF 7+, CODE 07)

Perishable foods are items that are either frozen or fresh; un-refrigerated or refrigerated food items that will spoil or suffer significant deterioration in quality within 1 to 3

weeks after purchase. Non-Perishable foods are items that are either canned, dried or shelf-stable that will NOT spoil or suffer significant deterioration in quality within 1

to 3 weeks after purchase.

Food items with multiple eligible ingredients (e.g., pizza, frozen dinners) will be counted only once as a staple food, in the category of the main ingredient.

Reminder: fresh and frozen preparations of the SAME food option should be counted once (example: fresh and frozen pineapple is one option).

11

K. EXTERIOR MARKETING

COUNT THE NUMBER

OF…

K1. on Building Exterior K2. on Property

TALLY AD TOTAL TALLY

PRICE PROMOTION

TOTAL TALLY AD

TOTAL TALLY PRICE

PROMOTION TOTAL

a. All Tobacco Advertisements (IF 10+, CODE

1. Ads that include Cigarettes

2. Ads that include Snus

3. Ads that include Moist Snuff

4. Ads that include E-cigarettes

5. Ads that include Cigarillos, flavored

6. Ads that include Cigarillos, unflavored

b. All Alcohol Advertisements (IF 10+, CODE 10)

1. Ads that include Beer

2. Ads that include Wine

3. Ads that include Liquor/Spirits

c. All Food and/or Beverage Advertisements (IF 20+, CODE 20)

1. Ads that include a Food

a. Ads that include Fresh Produce (salad, fruit, vegetables)

2. Ads that include a Beverage

a. Ads that include Regular Soda

b. Ads that include Diet Soda

c. Ads that include Regular Energy Drink

d. Ads that include Regular Sports Drink

e. Ads that include Milk

12

- -

J. Item Display

J1. End-aisle Displays J2. Special Floor Displays

NO YES NO YES

a. Fresh fruits 0 1 0 1

b. Fresh vegetables 0 1 0 1

c. Milk, unflavored 0 1 0 1

d. Soda, regular 0 1 0 1

e. Soda, diet 0 1 0 1

f. Other sweetened beverage 0 1 0 1

g. Bottled water 0 1 0 1

h. Salty snacks 0 1 0 1

i. Candy 0 1 0 1

j. Sweetened baked goods 0 1 0 1

M. STORE EXTERIOR

M1. Does the store have…? NO YES M3. How much graffiti/ tagging is on building and/or property?

NONE A LITTLE SOME A LOT

a. Parking On-Site IF NO, SKIP TO Mb 0 1 0 1 2 3

1. Lighted Parking 0 1 M4. How much garbage/litter is at the facility entrance area?

0 1 2 3 b. Bicycle Parking 0 1

c. Bars on Windows 0 1 NOTES

d. Security Guard, in store or retail compound 0 1

e. A sidewalk on street at address IF NO, SKIP TO M2

0 1

1. Sidewalk Lighting 0 1

M2. Does the store sell gasoline? 0 1

Notes:

Documents

Illinois PRC NOPREN FOOD STORE OBSERVATION FORM 2015 … · Supermarket (Jewel-Osco, Mariano’s, Safeway) 1 a. Bank 0 1 Grocery (Aldi, Trader Joe’s, Save A Lot, “mom & pop”)