HomeMy WebLinkAbout2001 Feb 22 - Tobacco Compliance Check Form MT���D: o�oao
Tobacco Comptiance Check Form 2000
Section 1:
Establishment -
Survey Participants
Name:
Chrlsty's of Cape Coc�#609 Name of Purchaser.
Address: Q.4j jVj�st. or IDn
—__
w• YaitTlout A�e' Sea: ❑ Male Female
h, MA 02673
City: Name ot A escort/Dat ollector:
Sample Area(if smaller than city or town please identifi�: ��
Time of Check: �-0 am (g p�n ❑
Type of Establishment: �Chain � Independent ❑ Not Kno�vn Date of Check �
Style of Establishment (CheCk �nly �ne):
Convenience Store . ❑ Pharmacy/Dru�Store
❑ Gas Station Only ❑ Gas Mini-Mart
0 Grocery Store` ❑ Liquor Store
❑ Department Store ❑ Bar
❑ Restaurant(Bar Area) ❑ Private Cfub(VFW, LeQion,etc.)
❑ Restaurant(Other Area1 ❑ Other(bowlinQ allev �olf club etc.)
Section 2:
Did the youth enter the premises and attempt to purchase a tobacco product? Yes No ❑
!f Yes p! ase continue on to the ne.rt qrrestion, if No please skip t{ris sectrof�u�td go to section 3.
Ho was tobacco marketed?
Over-the-counter:youth asks the clerk for the product.
❑ Over-the-counter:youth selects the product from a self-service display.
❑ From a vending machine with a lockout device.
❑ From a vending machine without a lockout device.
Was thePurchaser asked for ID? — /
Was the Purchaser asked his/her age? Yes No ❑ Was ID accurately checked? Yes ❑ No ❑ N/A [�'
Yes ❑ No� ���
Sex of Clerk: Male ❑ Female �" � Approximate a�e of clerk: �l�
Did the Clerh say anything to yo when the purchase attempt�vas made? -----�'
Type of tobacco asked for: � CiQa ttes � Chew/Dip ❑ Ci�ars Brand
Was the sale made? Yes � No� � � Other Please specif�
( f Yes ho�v much did [he product cost: ��_�
Section 3: " .
If the youth did not enter the premises or did not attempt to purchase tobacco products please check here: ❑ and ��di
❑ closed for the day cate�vh��
� couldn't locate business � bu��er kno�vs clerk/merchant
❑ closed for the season � no lon�er in business ❑ establishment inappropriate for vouth ❑ ot�l erS(spzc�far�e
❑ closed to the public ❑ doesn't sell tobacco y�
° � denied admission at door ❑ vendin�� � �nsafe�stablishment
machine broken � unsafe area
Please call the MTCP Evaluation Director at (617) 624-5900 if you have any questions.