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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?
a0047b9198494bf6b3e403eac1cb621b 18-24 
a0047b9198494bf6b3e403eac1cb621b 25-34 
a0047b9198494bf6b3e403eac1cb621b 35-44 
a0047b9198494bf6b3e403eac1cb621b 45-54 
a0047b9198494bf6b3e403eac1cb621b 55-64 
a0047b9198494bf6b3e403eac1cb621b 65-74 
a0047b9198494bf6b3e403eac1cb621b 75 years and older 
How do you identify?
a0047b9198494bf6b3e403eac1cb621b Male 
a0047b9198494bf6b3e403eac1cb621b Female 
a0047b9198494bf6b3e403eac1cb621b Transgender 
a0047b9198494bf6b3e403eac1cb621b Genderqueer 
a0047b9198494bf6b3e403eac1cb621b Other 
What is your race / ethnicity?
Select all that apply
882c5dc6cf714b95ad8824f4907f28e6 Black/African 
882c5dc6cf714b95ad8824f4907f28e6 Hispanic/Latino/Latinx 
882c5dc6cf714b95ad8824f4907f28e6 White/Caucasian 
882c5dc6cf714b95ad8824f4907f28e6 American Indian 
882c5dc6cf714b95ad8824f4907f28e6 Asian 
882c5dc6cf714b95ad8824f4907f28e6 Other 
What is your primary language(s) spoken?
882c5dc6cf714b95ad8824f4907f28e6 English 
882c5dc6cf714b95ad8824f4907f28e6 Other 
882c5dc6cf714b95ad8824f4907f28e6 Spanish 
882c5dc6cf714b95ad8824f4907f28e6 Arabic 
882c5dc6cf714b95ad8824f4907f28e6 French 
882c5dc6cf714b95ad8824f4907f28e6 Gujarati 
882c5dc6cf714b95ad8824f4907f28e6 Haitian Creole 
882c5dc6cf714b95ad8824f4907f28e6 Hindi 
882c5dc6cf714b95ad8824f4907f28e6 Italian 
882c5dc6cf714b95ad8824f4907f28e6 Mandarin 
882c5dc6cf714b95ad8824f4907f28e6 Polish 
882c5dc6cf714b95ad8824f4907f28e6 Portuguese 
882c5dc6cf714b95ad8824f4907f28e6 Tagalog 
Public Hearing Location
882c5dc6cf714b95ad8824f4907f28e6 Wednesday, November 2- Rutgers Camden - Campus Center Multipurpose Room, 326 Penn St., Camden, NJ 08102 - 4:30 - 8:00PM 
882c5dc6cf714b95ad8824f4907f28e6 Wednesday, November 9- Rutgers Newark - Rutgers New Jersey Medical School, Lecture Hall B552, 185 South Orange Ave., Newark, NJ 07103 - 4:30 - 8:00PM 
882c5dc6cf714b95ad8824f4907f28e6 Saturday, December 3- DCF Training Academy, 30 Van Dyke Ave., New Brunswick, NJ 08901 - 10:00 - 1:00pm 
882c5dc6cf714b95ad8824f4907f28e6 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
a0047b9198494bf6b3e403eac1cb621b No 
a0047b9198494bf6b3e403eac1cb621b Yes