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September 2023 PG Screening Registration
2023 Recovery Month PG Screening Event Registration
Thank you for making the time to screen the people you work with for problem gambling!
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1.
By checking this box I agree to complete a short follow up survey indicating the number of people I/my agency screened.
(Required.)
I agree
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2.
Name of agency:
(Required.)
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3.
Name of contact person:
(Required.)
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4.
Email address of contact person:
(Required.)
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5.
County your agency/practice serves:
(Required.)
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6.
Dates of your screening event:
(Required.)
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7.
Are you an OASAS provider?
(Required.)
Yes
No
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8.
Have you/your agency held a PG screening in before?
(Required.)
Yes
No
Current Progress,
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