Attachment_C_Survey_Form.pdf

ATTACHMENT C OF

TASK ORDER PERFORMANCE WORK

STATEMENT (PWS)

SURVEY FORM

SNAP STORE VISIT CONTRACT

FNS Number

GENERAL STORE INFORMATION (AS PROVIDED BY FIELD OFFICE)

Owner’s Name Provided by Store Personnel:

Store Name Posted:

Days & Hours of Operation Record Days & Hours of Operation in space provided here, indicating "a m " and/or "pm ". If a store is open different hours on certain days, please list those days separately. For example, Monday – Saturday, 7am-11pm; Sunday, 10am- 6pm. Write "Same" if hours are same as provided.

GENERAL STORE CHARACTERISTICS (Mark all that apply)

Description of Area: Urban Suburban Rural Other Description of Location: Residential Commercial Industrial Other Placement of Store: Freestanding Shopping

Center/Mall Farmers’ Market

Stall/Booth Other

YES NO Are optical scanners used at checkout?

YES NO Are shopping baskets available for customers?

YES NO Are there more than 10 shopping baskets for customers to use?

YES NO Are shopping carts available for customers?

YES NO Are there more than 10 shopping carts for customers to use?

If yes, take photos of carts and baskets in the store.

Number of Cash Registers/Check-out Stations? (If no registers present, answer the next question) YES NO Adding Machines/Calculators? Other Number of Point-of-Sale Devices for EBT Benefits Inside Store

YES NO Is there evidence of wholesale business such as posted prices or separate entrances for wholesale customers?

FOOD SERVICE INFORMATION (Mark All That Apply)

YES NO Hot Food Sold? (Take photo of hot food and menu or get copy of the menu, if available.)

YES NO Food Sold For On-Site Consumption (Hot OR Cold)? (If yes, mark next line, and take photo) If Yes… Chairs/Tables Counter/Booth Seating Standup Tables Other

YES NO Is There a Deli OR Prepared Food Section? (If yes, mark all that apply:)

If Yes… Prices Posted for Meats/

Cheeses Sold by Weight Prepared Salads Prepared/Made-to-

Order Sandwiches Other Refrigerated Foods (e.g., casseroles, Chilled Cooked Chicken, etc.)

YES NO Meat/Seafood Specials or Bundles, or Fruit/Vegetable Boxes Sold? (If Yes…Get Copy of Promotional Flyer or Take Photo.)

Survey Form for FNS or Authorized Agent Use Only U.S. Department of Agriculture - Food and Nutrition Service March 2012 - BRD/SNAP

NOTE: MARK APPROPRIATE BOXES WITH AN "X" CENTERED IN THE BOX.

Store Name:

Store Address: Telephone No:

County:

City/State/Zip:

Days/Hours of Operation:

What is the estimated square footage of the store?

Is food stored in a storage area out of the public view? YES NO If yes, include the storage area in the sketch and ask for the estimated square footage of that space and note it here.

YES NO Does the store operate through a night window or plastic barrier?

If yes, take photo of night window or plastic barrier.

STORE TYPE?

Is this store delivery route, farmers’ market or specialty food store primarily selling one food type such as meat, poultry, seafood, bread, fruits, or vegetables?

If Yes, circle type or, if another type, write in best description here:

NON-FOOD STOCK AND SERVICES (Mark any that are present)

Tobacco Products Alcohol Lottery tickets Gasoline Other (Briefly describe the items that are carried in significant amounts.)

Take Photos of Items Carried in Significant Amounts. (Reminder, a photo of alcohol and gas pumps is always required.)

STORE CONDITIONS (Mark all that apply)

(Explain Scope of Problem in Comments Section.)

Empty Coolers Empty Shelves Poor Lighting Ice Crystals on Frozen Food

Dusty Cans/Packages Expired/Outdated Food

Broken Coolers Faded/Missing Labels Other

COMMENTS:

Reviewer (Print Name): Signature (Original in Ink):

Site Visit, or 1st attempt: Date /_ _/_

(If applicable) Re-Visit, or 2nd attempt: Date _/ _/_

Arrival Time am/pm (circle one)

Arrival Time am/pm (circle one)

Survey Form for FNS or Authorized Agent Use Only U.S. Department of Agriculture - Food and Nutrition Service March 2012 - BRD/SNAP