Host Data Reporting Form

 

 

 

 

Thank you for hosting Gambling Disorder Screening Day. Screening Day is an international grassroots initiative made possible by people like you.

Please complete this optional form about the individuals whom you or your organization invited to participate and screened today. This information helps us estimate Screening Day need, reach and others indicators of progress.

Please do not include any Patient Health Information, such as patient name, on this form.

If you prefer to print a pdf of this form to complete, download a printable pdf of the Host Data Reporting Form.

For any questions about this form or Screening Day, email info@divisiononaddiction.org.