Before you begin the interview with a pharmacist, introduce yourself. Explain the purpose of the interview and ask the pharmacist if this is a good time for a 10-minute interview or if she/he will give you an appointment at another mutually convenient time. Discuss how results will be used. At the conclusion, don't forget to thank the pharmacist for his/her time.

A. Awareness

1. Approximately how many youth between the ages of 13 and 21 years come into your pharmacy for prescription items per week? __________
   
2. How often do youth under age 21 ask you questions about their health (i.e. skin problems, birth control, general aches and pains)?
   
   Daily __________
   Several times a week __________
   Several times a month __________
   Several times a year __________
   Never __________
   
3. Do you have a physical space in your pharmacy that can be used to counsel customers in private?
   
   Yes __________
   No __________
   
4. In the past year, have any youth under age 21 asked your advice about preventing pregnancy?
   
   Yes __________
   No __________
   
5. In the past year, approximately how often did youth bring in prescriptions or ask for emergency contraceptive pills (ECP)?
   
   Never __________
   Several times a year __________
   Several times a month __________
   Several times a week __________
   Don't know __________
   
6. Would your pharmacy be willing to disseminate inserts or pamphlets about ECP to customers who purchase condoms, pregnancy test kits, etc.?
   
   Yes __________
   No __________
   
7. Would your pharmacy be willing to display posters, pamphlets, etc. about ECP?
   
   Yes __________
   No __________
   
8. Does your pharmacy currently stock Plan B® or ECPs?
   
   Yes __________
   No __________

B. Attitudes

1. To what extent do you agree with the following statements?

	Completely Disagree	Somewhat Disagree	Somewhat Agree	Completely Agree	Not Sure
a. Emergency contraceptive pills are safe for adolescents.	1	2	3	4	5
b. Adolescents would not use other contraceptive methods effectively if ECPs were easily available.	1	2	3	4	5
c. Repeated use of ECP can pose health risks.	1	2	3	4	5
d. ECP should be available over the counter, without prescription for teens under 18.	1	2	3	4	5
e. ECP can cause birth defects if taken by pregnant women.	1	2	3	4	5

2. How comfortable are you talking to adolescents about emergency contraceptive pills?
   
   Very uncomfortable __________
   Somewhat uncomfortable __________
   Somewhat comfortable __________
   Very comfortable __________

Adapted with permission by Vincent McBride and Brenda Rhodes Miller, DC Campaign to Prevent Teen Pregnancy and Laura Davis, Advocates for Youth from a survey of Pharmacists' Awareness and Attitudes towards Emergency Contraception developed by the Academy for Educational Development in New York City.