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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?
76863052b22d4046b1152b045584c3cd 18-24 
76863052b22d4046b1152b045584c3cd 25-34 
76863052b22d4046b1152b045584c3cd 35-44 
76863052b22d4046b1152b045584c3cd 45-54 
76863052b22d4046b1152b045584c3cd 55-64 
76863052b22d4046b1152b045584c3cd 65-74 
76863052b22d4046b1152b045584c3cd 75 years and older 
How do you identify?
76863052b22d4046b1152b045584c3cd Male 
76863052b22d4046b1152b045584c3cd Female 
76863052b22d4046b1152b045584c3cd Transgender 
76863052b22d4046b1152b045584c3cd Genderqueer 
76863052b22d4046b1152b045584c3cd Other 
What is your race / ethnicity?
Select all that apply
31b02c089c1545dba4948a4a1941c455 Black/African 
31b02c089c1545dba4948a4a1941c455 Hispanic/Latino/Latinx 
31b02c089c1545dba4948a4a1941c455 White/Caucasian 
31b02c089c1545dba4948a4a1941c455 American Indian 
31b02c089c1545dba4948a4a1941c455 Asian 
31b02c089c1545dba4948a4a1941c455 Other 
What is your primary language(s) spoken?
31b02c089c1545dba4948a4a1941c455 English 
31b02c089c1545dba4948a4a1941c455 Other 
31b02c089c1545dba4948a4a1941c455 Spanish 
31b02c089c1545dba4948a4a1941c455 Arabic 
31b02c089c1545dba4948a4a1941c455 French 
31b02c089c1545dba4948a4a1941c455 Gujarati 
31b02c089c1545dba4948a4a1941c455 Haitian Creole 
31b02c089c1545dba4948a4a1941c455 Hindi 
31b02c089c1545dba4948a4a1941c455 Italian 
31b02c089c1545dba4948a4a1941c455 Mandarin 
31b02c089c1545dba4948a4a1941c455 Polish 
31b02c089c1545dba4948a4a1941c455 Portuguese 
31b02c089c1545dba4948a4a1941c455 Tagalog 
Public Hearing Location
31b02c089c1545dba4948a4a1941c455 Wednesday, November 2- Rutgers Camden - Campus Center Multipurpose Room, 326 Penn St., Camden, NJ 08102 - 4:30 - 8:00PM 
31b02c089c1545dba4948a4a1941c455 Wednesday, November 9- Rutgers Newark - Rutgers New Jersey Medical School, Lecture Hall B552, 185 South Orange Ave., Newark, NJ 07103 - 4:30 - 8:00PM 
31b02c089c1545dba4948a4a1941c455 Saturday, December 3- DCF Training Academy, 30 Van Dyke Ave., New Brunswick, NJ 08901 - 10:00 - 1:00pm 
31b02c089c1545dba4948a4a1941c455 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
76863052b22d4046b1152b045584c3cd No 
76863052b22d4046b1152b045584c3cd Yes 
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