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Public Hearing Pre-Registration

Thank you for your interest in participating in a Public Hearing hosted by the New Jersey Coronavirus Disease (COVID-19) Pandemic Task Force on Racial and Health Disparities.

Please take 2 minutes to complete our pre-registration survey.

If you have any questions, please email Jalisa Smith, Program Management Officer, at Jalisa.Smith@doh.nj.gov

Disclaimer:

The information provided is for planning and logistic purposes only. No information will be shared
First name ✱
Last name ✱
Phone number (Mobile)
Contact Information
 ✱
 ✱
What is your age group?
15a16491b4bb47a889e9a7eef8590dbb 18-24 
15a16491b4bb47a889e9a7eef8590dbb 25-34 
15a16491b4bb47a889e9a7eef8590dbb 35-44 
15a16491b4bb47a889e9a7eef8590dbb 45-54 
15a16491b4bb47a889e9a7eef8590dbb 55-64 
15a16491b4bb47a889e9a7eef8590dbb 65-74 
15a16491b4bb47a889e9a7eef8590dbb 75 years and older 
How do you identify?
15a16491b4bb47a889e9a7eef8590dbb Male 
15a16491b4bb47a889e9a7eef8590dbb Female 
15a16491b4bb47a889e9a7eef8590dbb Transgender 
15a16491b4bb47a889e9a7eef8590dbb Genderqueer 
15a16491b4bb47a889e9a7eef8590dbb Other 
What is your race / ethnicity?
Select all that apply
c2d1ecbb451b4ac4ad706e9f4ab95f33 Black/African 
c2d1ecbb451b4ac4ad706e9f4ab95f33 Hispanic/Latino/Latinx 
c2d1ecbb451b4ac4ad706e9f4ab95f33 White/Caucasian 
c2d1ecbb451b4ac4ad706e9f4ab95f33 American Indian 
c2d1ecbb451b4ac4ad706e9f4ab95f33 Asian 
c2d1ecbb451b4ac4ad706e9f4ab95f33 Other 
What is your primary language(s) spoken?
c2d1ecbb451b4ac4ad706e9f4ab95f33 English 
c2d1ecbb451b4ac4ad706e9f4ab95f33 Other 
c2d1ecbb451b4ac4ad706e9f4ab95f33 Spanish 
c2d1ecbb451b4ac4ad706e9f4ab95f33 Arabic 
c2d1ecbb451b4ac4ad706e9f4ab95f33 French 
c2d1ecbb451b4ac4ad706e9f4ab95f33 Gujarati 
c2d1ecbb451b4ac4ad706e9f4ab95f33 Haitian Creole 
c2d1ecbb451b4ac4ad706e9f4ab95f33 Hindi 
c2d1ecbb451b4ac4ad706e9f4ab95f33 Italian 
c2d1ecbb451b4ac4ad706e9f4ab95f33 Mandarin 
c2d1ecbb451b4ac4ad706e9f4ab95f33 Polish 
c2d1ecbb451b4ac4ad706e9f4ab95f33 Portuguese 
c2d1ecbb451b4ac4ad706e9f4ab95f33 Tagalog 
Public Hearing Location
c2d1ecbb451b4ac4ad706e9f4ab95f33 Wednesday, November 2- Rutgers Camden - Campus Center Multipurpose Room, 326 Penn St., Camden, NJ 08102 - 4:30 - 8:00PM 
c2d1ecbb451b4ac4ad706e9f4ab95f33 Wednesday, November 9- Rutgers Newark - Rutgers New Jersey Medical School, Lecture Hall B552, 185 South Orange Ave., Newark, NJ 07103 - 4:30 - 8:00PM 
c2d1ecbb451b4ac4ad706e9f4ab95f33 Saturday, December 3- DCF Training Academy, 30 Van Dyke Ave., New Brunswick, NJ 08901 - 10:00 - 1:00pm 
c2d1ecbb451b4ac4ad706e9f4ab95f33 Tuesday, December 6- Virtual Hearing, Zoom Meeting: https://us06web.zoom.us/j/85656596288,- 4:30 - 8:00pm 
Do you require special accommodations? If yes, please write down your accommodations
15a16491b4bb47a889e9a7eef8590dbb No 
15a16491b4bb47a889e9a7eef8590dbb Yes 
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