NJHealthLogo2.jpg

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?
603b62716dc44cb3886c52a4e580c73a 18-24 
603b62716dc44cb3886c52a4e580c73a 25-34 
603b62716dc44cb3886c52a4e580c73a 35-44 
603b62716dc44cb3886c52a4e580c73a 45-54 
603b62716dc44cb3886c52a4e580c73a 55-64 
603b62716dc44cb3886c52a4e580c73a 65-74 
603b62716dc44cb3886c52a4e580c73a 75 years and older 
How do you identify?
603b62716dc44cb3886c52a4e580c73a Male 
603b62716dc44cb3886c52a4e580c73a Female 
603b62716dc44cb3886c52a4e580c73a Transgender 
603b62716dc44cb3886c52a4e580c73a Genderqueer 
603b62716dc44cb3886c52a4e580c73a Other 
What is your race / ethnicity?
Select all that apply
a9286866a6c54e86ab5c7385024cfb66 Black/African 
a9286866a6c54e86ab5c7385024cfb66 Hispanic/Latino/Latinx 
a9286866a6c54e86ab5c7385024cfb66 White/Caucasian 
a9286866a6c54e86ab5c7385024cfb66 American Indian 
a9286866a6c54e86ab5c7385024cfb66 Asian 
a9286866a6c54e86ab5c7385024cfb66 Other 
What is your primary language(s) spoken?
a9286866a6c54e86ab5c7385024cfb66 English 
a9286866a6c54e86ab5c7385024cfb66 Other 
a9286866a6c54e86ab5c7385024cfb66 Spanish 
a9286866a6c54e86ab5c7385024cfb66 Arabic 
a9286866a6c54e86ab5c7385024cfb66 French 
a9286866a6c54e86ab5c7385024cfb66 Gujarati 
a9286866a6c54e86ab5c7385024cfb66 Haitian Creole 
a9286866a6c54e86ab5c7385024cfb66 Hindi 
a9286866a6c54e86ab5c7385024cfb66 Italian 
a9286866a6c54e86ab5c7385024cfb66 Mandarin 
a9286866a6c54e86ab5c7385024cfb66 Polish 
a9286866a6c54e86ab5c7385024cfb66 Portuguese 
a9286866a6c54e86ab5c7385024cfb66 Tagalog 
Public Hearing Location
a9286866a6c54e86ab5c7385024cfb66 Wednesday, November 2- Rutgers Camden - Campus Center Multipurpose Room, 326 Penn St., Camden, NJ 08102 - 4:30 - 8:00PM 
a9286866a6c54e86ab5c7385024cfb66 Wednesday, November 9- Rutgers Newark - Rutgers New Jersey Medical School, Lecture Hall B552, 185 South Orange Ave., Newark, NJ 07103 - 4:30 - 8:00PM 
a9286866a6c54e86ab5c7385024cfb66 Saturday, December 3- DCF Training Academy, 30 Van Dyke Ave., New Brunswick, NJ 08901 - 10:00 - 1:00pm 
a9286866a6c54e86ab5c7385024cfb66 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
603b62716dc44cb3886c52a4e580c73a No 
603b62716dc44cb3886c52a4e580c73a Yes 
Online Survey Software Powered by novisurvey.net