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?
10398b51bc6b41389b47dfb906ec221d 18-24 
10398b51bc6b41389b47dfb906ec221d 25-34 
10398b51bc6b41389b47dfb906ec221d 35-44 
10398b51bc6b41389b47dfb906ec221d 45-54 
10398b51bc6b41389b47dfb906ec221d 55-64 
10398b51bc6b41389b47dfb906ec221d 65-74 
10398b51bc6b41389b47dfb906ec221d 75 years and older 
How do you identify?
10398b51bc6b41389b47dfb906ec221d Male 
10398b51bc6b41389b47dfb906ec221d Female 
10398b51bc6b41389b47dfb906ec221d Transgender 
10398b51bc6b41389b47dfb906ec221d Genderqueer 
10398b51bc6b41389b47dfb906ec221d Other 
What is your race / ethnicity?
Select all that apply
8f114eb3295041c7a39747ff84c81366 Black/African 
8f114eb3295041c7a39747ff84c81366 Hispanic/Latino/Latinx 
8f114eb3295041c7a39747ff84c81366 White/Caucasian 
8f114eb3295041c7a39747ff84c81366 American Indian 
8f114eb3295041c7a39747ff84c81366 Asian 
8f114eb3295041c7a39747ff84c81366 Other 
What is your primary language(s) spoken?
8f114eb3295041c7a39747ff84c81366 English 
8f114eb3295041c7a39747ff84c81366 Other 
8f114eb3295041c7a39747ff84c81366 Spanish 
8f114eb3295041c7a39747ff84c81366 Arabic 
8f114eb3295041c7a39747ff84c81366 French 
8f114eb3295041c7a39747ff84c81366 Gujarati 
8f114eb3295041c7a39747ff84c81366 Haitian Creole 
8f114eb3295041c7a39747ff84c81366 Hindi 
8f114eb3295041c7a39747ff84c81366 Italian 
8f114eb3295041c7a39747ff84c81366 Mandarin 
8f114eb3295041c7a39747ff84c81366 Polish 
8f114eb3295041c7a39747ff84c81366 Portuguese 
8f114eb3295041c7a39747ff84c81366 Tagalog 
Public Hearing Location
8f114eb3295041c7a39747ff84c81366 Wednesday, November 2- Rutgers Camden - Campus Center Multipurpose Room, 326 Penn St., Camden, NJ 08102 - 4:30 - 8:00PM 
8f114eb3295041c7a39747ff84c81366 Wednesday, November 9- Rutgers Newark - Rutgers New Jersey Medical School, Lecture Hall B552, 185 South Orange Ave., Newark, NJ 07103 - 4:30 - 8:00PM 
8f114eb3295041c7a39747ff84c81366 Saturday, December 3- DCF Training Academy, 30 Van Dyke Ave., New Brunswick, NJ 08901 - 10:00 - 1:00pm 
8f114eb3295041c7a39747ff84c81366 Tuesday, December 6- Virtual Hearing, Zoom Meetinghttps://us06web.zoom.us/j/85656596288,4:30 - 8:00pm 
Do you require special accommodations? If yes, please write down your accommodations
10398b51bc6b41389b47dfb906ec221d No 
10398b51bc6b41389b47dfb906ec221d Yes