1. 1
Date_______________ Time______________
Store Name________________________________________________________________________________________
Address___________________________________________________________________________________________
Please remember to introduce yourself to the clerk. This is a place of business and it is important that you are not in the way of
customers. An example of how to introduce yourself: Hi, my name is ___________. I’m from Montclair State University and we are
working on a project to see what different tobacco products are sold in different businesses. Would it be okay if we walked around
the store?
Be courteous and if employers asks you to leave, do so immediately.
Step 1: Type of Store (Check one)
☐ Supermarket & grocery ☐ Convenience Store ☐ Gas Station ☐ Pharmacy or Drug Store ☐ Tobacco Store
☐ Beer, wine and Liquor Store ☐ Other_____________________________________________________________________
Step 2: Can you see a school from this store?
☐ Yes ☐ No If yes, estimate how far away it is ☐ ½ a block away ☐ 1 block away ☐ More than 1 block away
Step 3: Is there a place that youth hang out nearby? Check all that apply and how far it is
☐ Park........................................................................................................................... ☐ ½ a block away ☐ 1 block away ☐ More than 1 block away
☐ Place of worship……………………..................................................................................☐ ½ a block away ☐ 1 block away ☐ More than 1 block away
☐ Popular restaurant…………………………………………………………………………………….………....☐ ½ a block away ☐ 1 block away ☐ More than 1 block away
☐ Other_____________________________________________________________ ☐ ½ a block away ☐ 1 block away ☐ More than 1 block away
☐ Other_____________________________________________________________ ☐ ½ a block away ☐ 1 block away ☐ More than 1 block away
Step 4: How far is this business from other tobacco retailers?
☐ ½ a block away ☐ 1 block away ☐ More than 1 block away
Step 5: Signage
Is there signage of 18 to purchase?.......................................................................................................................................................………☐ Yes ☐ No
Is there signage of 21 to purchase?................................................................................................................................................................☐ Yes ☐ No
Is there signage that loosies are sold?........................................................................................................................................................... ☐ Yes ☐ No
Step 6: Store Exterior
Are there ads on the store doors or windows?..............................................................................................................................................☐ Yes ☐ No
Are there ads on the building walls?..............................................................................................................................................................☐ Yes ☐ No
Are there ads in the parking lot or on property fences?.................................................................................................................................☐ Yes ☐ No
Are there ads on functional items? e.g trashcans, benches……………………………………………………………….............................................................☐ Yes ☐ No
Are there ads in other places?...................................................................................☐ Yes ☐ No If yes, where_______________________________
Step 7: Product Availability Here you are recording different types of products sold at the store. Check yes or no.
Are cigarettes sold?........................................................................................................................................................................................☐ Yes ☐ No
Are Cigars sold?..............................................................................................................................................................................................☐ Yes ☐ No
Environmental Scan: Paterson, NJ
For each store you visit please fill out the information below.
Please turn page over

2. 2
Are E-Cigarettes sold?....................................................................................................................................................................................☐ Yes ☐ No
If yes, are there flavored E-cigarettes?..................................................................................................................................................☐ Yes ☐ No
Are flavored E-cigarettes sold?.......................................................................................................................................................................☐ Yes ☐ No
Are smokeless tobacco sold (chew, dip, snuf)................................................................................................................................................☐ Yes ☐ No
Are hookah tobacco refills sold?....................................................................................................................................................................☐ Yes ☐ No
If yes, are the flavored refills sold?.........................................................................................................................................................☐ Yes ☐ No
Is there tobacco/marijuana paraphernalia sold (pipes, hookah)?........................................................................... ......................................☐ Yes ☐ No
Are there any tobacco products that look like candy?...................................................................................................................................☐ Yes ☐ No
Are there loosies being sold?.........................................................................................................................................................................☐ Yes ☐ No
Are snacks or food sold?.................................................................................................................................................................................☐ Yes ☐ No
Step 8: Product Placement
Are there any tobacco products displayed within 12” of candy?...................................................................................................................☐ Yes ☐ No
Are there any tobacco products displayed below 3ft?...................................................................................................................................☐ Yes ☐ No
Is tobacco sold behind the counter?............................................................................................................................................................. ☐ Yes ☐ No
Are e-cigarettes sold behind the counter?.................................................................................................................................................... ☐ Yes ☐ No
Is tobacco sold in front of the counter?........................................................................................................................................................ ☐ Yes ☐ No
Are e-cigarettes in front of the counter?....................................................................................................................................................... ☐ Yes ☐ No
Step 9: Advertisements
Are there advertisements for tobacco inside?................................................................................................................................................☐ Yes ☐ No
Are there advertisements for e-cigarettes inside?.........................................................................................................................................☐ Yes ☐ No
Are there ads on, near or behind the counter?..............................................................................................................................................☐ Yes ☐ No
Is there a tobacco wall?..................................................................................................................................................................................☐ Yes ☐ No