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I. Fast Food Restaurant Post Assessment

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* Survey Number (for office use only)

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* Name of Facilitator

Shannon Engel-Huron County

Lucinda Smith-Sanilac County

Mary Smith-Tuscola County

Other (please specify)

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* Date Survey Completed

Enter in form 10/01/2006

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* Is this a

Pre survey

Post Survey

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* Store Name

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* Name of Person Completing Form

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* 1.2b Check the menu items/options offered at each restaurant. If you only have one restaurant, leave restarant 2 and 3 columns blank. (check all that apply)

	Restaurant #1	Restaurant #2	Restaurant #3
Items identified on the menu that are low in calories and fat (not low carb), such as fruit	Items identified on the menu that are low in calories and fat (not low carb), such as fruit Restaurant #1	Items identified on the menu that are low in calories and fat (not low carb), such as fruit Restaurant #2	Items identified on the menu that are low in calories and fat (not low carb), such as fruit Restaurant #3
Low-fat muffins	Low-fat muffins Restaurant #1	Low-fat muffins Restaurant #2	Low-fat muffins Restaurant #3
Bagels or English Muffins	Bagels or English Muffins Restaurant #1	Bagels or English Muffins Restaurant #2	Bagels or English Muffins Restaurant #3
Milk	Milk Restaurant #1	Milk Restaurant #2	Milk Restaurant #3
Skim or 1% Milk	Skim or 1% Milk Restaurant #1	Skim or 1% Milk Restaurant #2	Skim or 1% Milk Restaurant #3
100%Fruit juice (not fruit punch, lemonade, or fruit drinks)	100%Fruit juice (not fruit punch, lemonade, or fruit drinks) Restaurant #1	100%Fruit juice (not fruit punch, lemonade, or fruit drinks) Restaurant #2	100%Fruit juice (not fruit punch, lemonade, or fruit drinks) Restaurant #3
Vegetable or broth-based soups (not cream-based)	Vegetable or broth-based soups (not cream-based) Restaurant #1	Vegetable or broth-based soups (not cream-based) Restaurant #2	Vegetable or broth-based soups (not cream-based) Restaurant #3
Plain baked potato	Plain baked potato Restaurant #1	Plain baked potato Restaurant #2	Plain baked potato Restaurant #3
Nutrition analysis on foods available	Nutrition analysis on foods available Restaurant #1	Nutrition analysis on foods available Restaurant #2	Nutrition analysis on foods available Restaurant #3
Light(reduced-fat) mayonnaise available	Light(reduced-fat) mayonnaise available Restaurant #1	Light(reduced-fat) mayonnaise available Restaurant #2	Light(reduced-fat) mayonnaise available Restaurant #3
At least one healthy option on the childrens menu (for example, grilled chicken with fruit and/or vegetable rather than fries)	At least one healthy option on the childrens menu (for example, grilled chicken with fruit and/or vegetable rather than fries) Restaurant #1	At least one healthy option on the childrens menu (for example, grilled chicken with fruit and/or vegetable rather than fries) Restaurant #2	At least one healthy option on the childrens menu (for example, grilled chicken with fruit and/or vegetable rather than fries) Restaurant #3
Leafy green salads	Leafy green salads Restaurant #1	Leafy green salads Restaurant #2	Leafy green salads Restaurant #3
Reduced calorie or fat-free salad dressings	Reduced calorie or fat-free salad dressings Restaurant #1	Reduced calorie or fat-free salad dressings Restaurant #2	Reduced calorie or fat-free salad dressings Restaurant #3

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* Total # of items/options check for Restaurant #1

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* Total # of items/options check for Restaurant #2. Leave blank if you only have one restaurant.

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* Total # of items/options checked for Restaurant #3. Leave blank if you only have one or two restaurants.