Alabama Department of Public Health



Survey Instructions

This survey is a tool for you to look at healthy foods (specifically fruits and vegetables) and beverages offered, how these foods and beverages are marketed, as well as areas for improvement in this store.

Your name: _________________________________________ Today’s date: ____________________

Store name: ________________________________________________________________________

Store address: _________________________________ E-mail address_________________________

Store phone number: ______________________ Hours of operation: _____________________

Circle one. Are you the manager, owner, store clerk, or other? If other, describe ________________

How long have you been with working this store? ______years ______months _______N/A

Please select which best describes this store.

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Nutritional Quality

This section focuses on variety. It asks about the types of fruits, vegetables, and beverages the store offers.

How many varieties does this store offer of each of the following types of vegetables? Circle your response.

|Fresh: |None |1-2 |3-4 |5+ |

|Frozen: |None |1-2 |3-4 |5+ |

|Canned: |None |1-2 |3-4 |5+ |

If the store carries frozen vegetables, how many are plain, low sodium, or have no added salt? _____

If the store carries canned vegetables how many are low sodium or have no added salt? _____

(Look on the front of the package or can for these words.)

How many varieties does the store offer of each of the following types of fruit? Circle your response.

|Fresh: |None |1-2 |3-4 |5+ |

|Frozen: |None |1-2 |3-4 |5+ |

|Canned: |None |1-2 |3-4 |5+ |

If the store carries frozen fruit, how many have no added sugars? _____

If the store carries canned fruit, how many are canned in 100% juice? (No heavy syrup) _____

(Look on the front of the package or can for these words.)

Please select the option that best describes the overall quality of fresh fruit and vegetables offered at your location. Circle your response.

|Fresh Fruit: |Excellent |Good |Fair |Poor |

| |(good color, no bruising, | | |(has bruising, rotting, brown spots, |

| |rotting, or brown spots) | | |etc.) |

|Fresh Vegetables: |Excellent |Good |Fair |Poor |

| |(good color, no bruising, | | |(has bruising, rotting, brown spots, |

| |rotting, or brown spots) | | |etc.) |

Does the store offer the following? Please circle yes or no.

|Full fat milk by the gallon or half gallon ( Vitamin D, Whole, or 2% Milk) |Yes |No |

|Low fat milk by the gallon or half gallon (1% or fat free) |Yes |No |

|Low fat milk in individual serving cartons ( 1% or fat free) |Yes |No |

|Bottled water or seltzer water |Yes |No |

|100% fruit juice options |Yes |No |

|At least 3 other beverage options with 40 calories or less per serving |Yes |No |

|(examples: unsweetened iced tea, low calorie flavored waters, diet sodas) | | |

|Dried Fruit with no sugar added (raisins, mangos, pineapple, etc.) |Yes |No |

Promotional Material and Visual Appearance

The way food and beverages are displayed and marketed play a role in the choices people make. This portion asks questions about how foods and beverages are displayed, and types of marketing tools used.

Does the store offer the following? Please circle yes or no.

|Whole fruit options displayed in attractive bowls, baskets, or shelving |Yes |No |

| | | |

|All fruit and vegetable names are printed or written legibly on product id or price cards, and are displayed appropriately next to |Yes |No |

|each item | | |

|Low fat milk, water, 100% fruit Juice, and any other beverage with 40 calories or less are on refrigerator shelves at eye level |Yes |No |

|Fruit and vegetable options are in high traffic areas easily seen by customers |Yes |No |

|If the store has a deli, is there an option for a meal combo that includes fruits and/or vegetables? |Yes |No |

|( Next 2 questions intended for corner and convenience stores only) At least one fruit option is available near all registers |Yes |No |

|All beverage coolers have at least one of the following in them at all times: low fat milk, water, 100% fruit juice, and any other |Yes |No |

|beverage with 40 calories or less | | |

Comments: _______________________________________________________________________________

Does the store have promotional materials related to healthy foods? (Circle one) Yes / No

If you answered yes please indicate where these promotional materials are displayed by selecting all that apply. If you answered no please indicate where there is space available for displaying promotional materials in the store.

| |Yes/space available |No/ no space available |Don’t know |

|Windows | | | |

|Exterior wall space | | | |

|Next to registers | | | |

|Interior wall space | | | |

|Counter space | | | |

Comments: _______________________________________________________________________________

This section for store owners or managers to answer

(If you are not a store owner or manager please get this information from the store owner or manager if possible)

Other spaces where promotional materials are displayed or could be displayed:

__________________________________________________________________________________________

What are the top 3 selling food items in your store?

1.___________________________2.___________________________3.________________________

What are the top 3 selling beverages in your store?

1.__________________________2.__________________________3.__________________________

Are there any healthier items that you are interested in selling? (Circle one) Yes / No

If so, what are they?

__________________________________________________________________________________________

__________________________________________________________________________________________

What are some challenges you face offering more healthful foods in your store?

____________________________________________________________________________________________________________________________________________________________________________________

How can we best help you sell healthier foods in your store?

____________________________________________________________________________________________________________________________________________________________________________________

Thank you for your time.

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Checkout a Good Choice

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