HomeMy WebLinkAbout2003 Dec 18 - Tobacco Compliance Check Form 1
�,MTCP�ID: /.�f(J� Tabaeco Comgliance �heck Form 2UQ3��OQ4 �.
SectiQn 1: `
' EstabIisbment Surve�r Fartieipar�ts
�
� Name: � �
� -
I Address• ��1� �/L�I'Jit��� NameJID of Purchaser:
�� Age: 0 15 ❑ 16 I� 17
� Sex: []Male I�Female
! ��/- � Name of Adult Supervisor: � �
� CitY: 2ip Code: (o �y
� Time of Check: V S 0� am�g,.pm❑
�
Type of Establishment: ❑ Chain Independent ❑ Not Known Date of Check:�Z � C�3
� Day of the Week � Mon Tues 0 Wed
j �,Thurs �Fri D Sat ❑Sun
a
j
� sryl f Escablishmenc(Gheck Only One): � �
�
� Convenience Store ❑Groc Store p g�
' � D artment Store �Li uar Store ❑Private Club(VFW,Le ion.etc.)
! 0 Gas Stadon Onl O Pharmac /Dru Store ❑R�estaurant(Bar Area)
� 0 Gas Mini-Mart ❑Other wlin alle , olf ciub etc.) ❑Restaurant(Other Area)
� .
� Sec�ion 2.
I�id the�auth enter the premises and �ttemgt tu gurc�ase a tahacca grc�duct?Y'es �. NQ Q
If Yes please conrinue on to the nea7 question, if No please skip this secrion and go to sectiorc 3.
How was tobacco marketed?
�Over-the-counter:youth asks the clerk for the product.
❑ From a vending machine with a locicout device.
❑ Other Desciibe:
Was the Purchaser asked for ID? Yes� No J� Was ID accurately checked? Yes� No❑ N/A❑
Was the Purchaser asked his/her age? Yes D No(�, C� V�� �`��r(�,
c7
Sex of Clerk: Male 0 Female� Approximate age of clerk:�Teen ❑Young Adult 0 Adult ❑Older Adult
Type of tobacco asked for: �Cigarettes Brand of cigarettes asked for: ❑ Marlboro �I Newport �Other:
, 0 Chew/Dig ❑ Cigars I� Other Brund:
Was the-sale made? Yes�. I�o � •�,
If"Yes"how much did the product cost: $,�_ •
Purchaser made payment using: ❑$1 bills ❑ $5 biIl ❑ $5 bill and$1 bills ❑ $10 bill� $20 bill ❑ quarters
Section 3:
If the youth did not enter the premises or did not attempt to purchase tobacco products please indicate�vhy: �
D closed for the da 0 c�uldn't locate business ❑ bu er knows clerk/merchant ❑ admission char e
� closed for the season � no lon er in business � establishment ina ro riate for outh 0 other(s eci )
❑ closed to the ublic ❑ doesn't sell tobacco ❑ unsafe establishment
� denied admission at door ❑ vendin machine broken ❑ unsafe area
8l27/03
S:1SharedlTOBACCO�STAFFISULLIVAMSynarlrevised IyITCP compliance check form 03.cfx