Thank you for hosting a screening event in honor of Gambling Disorder Screening Day!

Please complete this form about the individuals whom your organization screened today.  This information will help us estimate progress in our outreach and need for additional efforts.

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* 1. Name of Agency/Organization/Location:

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* 2. Is your agency an OASAS provider?

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* 3. County of Service:

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* 4. Dates of your screening:

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* 5. Total number of individuals screened:

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* 6. Did any of the individuals screen positive? (i.e. answered "yes" to at least one question on the BBGS)

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