BTG‐COMP ▪ FOOD STORE OBSERVATION FORM ▪ 2012
BUSINESS ID:
1 4‐1 2‐
‐
CORRESPONDING SEGMENT UNIT ID:
BUSINESS ID :
COMPLETION CODE COMPLETED
01
BUSINESS NAME:
PARTIALLY COMPLETED – CODE DISPOSITION
02
ADDRESS:
NOT STARTED – CODE DISPOSITION
03
NOT ELIGIBLE – CODE DISPOSITION
96
DATE STAFF 1 STAFF 2 ‐ ‐ 2012 AM
: START TIME END TIME PM
DISPOSITION CODE AM
:
Temporarily not accessible / Outside business hours
PM
LITTERED CIGARETTE PACKS No Cellophane With Cellophane Not safe Number of bags used:
BUSINESS SAMPLE ATTRIBUTES
0
Business replaces a primary sample observation
1
2
Asked to leave / Observation not allowed by staff
3
5
Does not meet study criteria – DESCRIBE IN NOTES
7
Permanently closed / Does not exist
8
YES Address not found
NO
Business is within ¼ mile of index school
1
0
NOTES
1
Other (SPECIFY):
6
A. GENERAL AND CHECK‐OUT A1. TYPE OF STORE Supermarket (Jewel‐Osco, Kroger, Safeway)
1
Grocery (Aldi, Trader Joe’s, “mom & pop”)
2
Limited Service CODE A1a
3
A1a. TYPE OF LIMITED SERVICE – CODE ONLY IF A1=3
A4. Does the store have a plexiglass or other divider at the cash register? A5. Number of cash registers (IF 10+, CODE 10) A6. Fast food or other individual, ready‐to eat items available ?
Convenience Store (7‐11, White Hen, ampm)
1
Small Discount Store (Dollar General, 99¢ Store)
2
a. Salads/salad bar
Drug Store/Pharmacy (CVS, Rite Aid, Walgreens)
3
Liquor Store (Ryan’s Liquor and Mini Mart) Other, SPECIFY: A2. Are these available at CHECK‐OUT?
b. Sandwiches (cold)
0
1
5
c. Pizza
0
1
4
d. Hot dogs/corn dogs/hamburgers
0
1
e. Mexican (tacos, burritos, taquitos, etc.)
0
1
e. Fresh fruits or vegetables
0
1
c. Bottled water
0
1
d. Sweetened beverages (soda, etc.)
0
1
NO
YES
a. Bank
0
1
b. Pharmacy
0
1
c. Butcher or fresh meat service counter
0
1
d. Deli counter
0
1
e. Bakery
0
1
Page 1 of 7
YES 1
YES 1
A3. Does the store have a…?
YES 1
NO 0
NO 0
a. Candy
NO 0
A7. Is 50% or more of the store’s inventory beer, wine, and/or liquor?
NO 0
YES 1
TOBACCO SUPPLEMENT SCREENER J1. Does the store sell any over‐the‐counter Nicotine Replacement Products?
NO
YES
(e.g., Nicorette gum, Commit lozenges, Nicoderm)
J2. Does the store sell any tobacco products?
IF YES, ATTACH TOBACCO SUPPLEMENT
0
0
NOTES
Copyright © 2012 The Board of Trustees of the University of Illinois
6666584359
1
1
B. FRESH PRODUCE
1 4‐1 2‐
MARK “X” IF NONE AVAILABLE AND SKIP SECTION B IF B1= NO, SKIP B2‐B7
B1. AVAILABLE
a. Apples
b. Bananas
c. Oranges
NO
YES
0
1
0
0
d. Grapes
0
e. Carrots
0
f. Tomatoes
g. Broccoli h. Lettuce
0
0 0
NO
1
1
1
1
1
1 1
YES
B3. QUALITY
B2. TYPE IF None, SKIP B3‐B7
POOR*
B4. QTY
B6. CURRENT PRICE
B5. UNIT IF None, SKIP B6‐B7
OK
‐
IF 77.77 (DK), SKIP B7
Pound
1
Piece
2
$
.
8
None of above
8
Loose?
N
Regular yellow
1
Pound
1
None of above
8
.
2 $ Loose? 8
Navel
1
Red Delicious
1
Granny Smith
2
None of above
1
1
2
2
Piece None of above
1
2
N
Pound
1
Piece
2
$
.
Loose?
N
Valencia
2
None of above
8
None of above
8
Red Seedless
1
Pound
1
Green
2
Bunch
2
$
.
None of above
8
None of above
8
Loose?
N
Full‐sized
1
Pound
1
Bunch
2
$
.
Loose?
N
1
1
2
2
Baby‐sized
2
None of above
8
None of above
8
Regular slicing
1
Pound
1
Piece
2
$
.
Loose?
N
1
2
Roma
2
None of above
8
None of above
8
Bunch
1
Pound
1
Bunch
2
$
. N
1
2
Crown
2
None of above
8
None of above
8
Loose?
Iceberg
1
Pound
1
Head
2
$
.
None of above
8
Loose?
N
Romaine
2
None of above
8
1
POOR*
OK
2
B8. Total number of Fresh Fruit options
(IF 20+, CODE 20)
B9. Total number of Fresh Vegetable options
(IF 20+, CODE 20)
B7. PRICE TYPE REG
SPECIAL
1
2
1
2
1
2
1
2
1
2
1
2
1
2
1
2
Y
Y
Y
Y
Y
Y
Y
Y
REG
SPECIAL
NOTES: NOTES
* ≥ 25% of product batch is poor quality * ≥ 25% of product batch is poor quality Page 2 of 7
Copyright © 2012 The Board of Trustees of the University of Illinois
8780584358
C. DAIRY, EGGS and MEAT
1 4‐1 2‐
MARK “X” IF NONE AVAILABLE AND SKIP SECTION C IF C1= NO, SKIP C2‐C6
C1. AVAILABLE NO
a. Milk, whole (vitamin D), unflavored
0
b. Milk, 2% fat,
0
unflavored
c. Milk, 1% fat,
0
unflavored
d. Milk, skim (fat free),
0
YES
1
1
1
1
C2. BRAND
Least Expensive
Least Expensive
Least Expensive
Least Expensive
C3. QTY
unflavored
0
e. Eggs
1
Least Expensive
C4. PACKAGE SIZE IF None SKIP C5‐C6
0
g. Low or reduced fat Cheese IF C1= NO, SKIP C2‐C6
0
1
½ Gallon
2
$
.
None of above
8
Asked?
N
Gallon
1
½ Gallon
2
$
.
None of above
8
Asked?
N
Gallon
1
½ Gallon
2
$
.
None of above
8
Asked?
N
Gallon
1
½ Gallon
2
$
.
None of above
8
Asked?
N
Dozen
1
½ Dozen
2
0
1
C2. FAT CONTENT
C3. QTY
j. Any Fresh Meat
1
2
1
2
1
2
1
2
1
2
Y
Y
Y
.
$
C5. CURRENT PRICE
IF None SKIP C5‐C6
IF 77.77 (DK), SKIP C6
1
% lean IF DK, SPECIFY CUT:
Pound
1
None of above
8
1
1
C6. PRICE TYPE
IF DK, SPECIFY CUT:
SPECIAL
$
.
1
2
$
.
1
2
Pound
1
None of above
8
0
REG
% lean 0
SPECIAL
Y
C4. UNIT
REG
YES
% fat
i. Ground Beef, extra lean (≤10% fat)
8
C6. PRICE TYPE
(Sliced, shredded or block cheese, any flavor – Do not include cottage cheese, cream cheese, soy cheese, imitation cheese, or pasteurized process cheese products)
% fat
h. Ground Beef, regular (≥20% fat)
IF 77.77 (DK), SKIP C6
1
C1. AVAILABLE NO
C5. CURRENT PRICE
Gallon
None of above
f. Cheese
‐
(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 Page 3 of 7
Copyright © 2012 The Board of Trustees of the University of Illinois
1428584350
D. CEREALS and BREADS IF D1= NO, SKIP D2‐D6
D1. AVAILABLE NO
D2. BRAND IF None, SKIP D3‐D6
a. Cereal, higher sugar content (≥ 6g sugar/svg)
0
b. Cereal, lower sugar content (
