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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?
c3b9ab3146704650be431500cb0ed314 18-24 
c3b9ab3146704650be431500cb0ed314 25-34 
c3b9ab3146704650be431500cb0ed314 35-44 
c3b9ab3146704650be431500cb0ed314 45-54 
c3b9ab3146704650be431500cb0ed314 55-64 
c3b9ab3146704650be431500cb0ed314 65-74 
c3b9ab3146704650be431500cb0ed314 75 years and older 
How do you identify?
c3b9ab3146704650be431500cb0ed314 Male 
c3b9ab3146704650be431500cb0ed314 Female 
c3b9ab3146704650be431500cb0ed314 Transgender 
c3b9ab3146704650be431500cb0ed314 Genderqueer 
c3b9ab3146704650be431500cb0ed314 Other 
What is your race / ethnicity?
Select all that apply
2bae0d7dd24144eabf0c49c4cd9856db Black/African 
2bae0d7dd24144eabf0c49c4cd9856db Hispanic/Latino/Latinx 
2bae0d7dd24144eabf0c49c4cd9856db White/Caucasian 
2bae0d7dd24144eabf0c49c4cd9856db American Indian 
2bae0d7dd24144eabf0c49c4cd9856db Asian 
2bae0d7dd24144eabf0c49c4cd9856db Other 
What is your primary language(s) spoken?
2bae0d7dd24144eabf0c49c4cd9856db English 
2bae0d7dd24144eabf0c49c4cd9856db Other 
2bae0d7dd24144eabf0c49c4cd9856db Spanish 
2bae0d7dd24144eabf0c49c4cd9856db Arabic 
2bae0d7dd24144eabf0c49c4cd9856db French 
2bae0d7dd24144eabf0c49c4cd9856db Gujarati 
2bae0d7dd24144eabf0c49c4cd9856db Haitian Creole 
2bae0d7dd24144eabf0c49c4cd9856db Hindi 
2bae0d7dd24144eabf0c49c4cd9856db Italian 
2bae0d7dd24144eabf0c49c4cd9856db Mandarin 
2bae0d7dd24144eabf0c49c4cd9856db Polish 
2bae0d7dd24144eabf0c49c4cd9856db Portuguese 
2bae0d7dd24144eabf0c49c4cd9856db Tagalog 
Public Hearing Location
2bae0d7dd24144eabf0c49c4cd9856db Wednesday, November 2- Rutgers Camden - Campus Center Multipurpose Room, 326 Penn St., Camden, NJ 08102 - 4:30 - 8:00PM 
2bae0d7dd24144eabf0c49c4cd9856db Wednesday, November 9- Rutgers Newark - Rutgers New Jersey Medical School, Lecture Hall B552, 185 South Orange Ave., Newark, NJ 07103 - 4:30 - 8:00PM 
2bae0d7dd24144eabf0c49c4cd9856db Saturday, December 3- DCF Training Academy, 30 Van Dyke Ave., New Brunswick, NJ 08901 - 10:00 - 1:00pm 
2bae0d7dd24144eabf0c49c4cd9856db 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
c3b9ab3146704650be431500cb0ed314 No 
c3b9ab3146704650be431500cb0ed314 Yes 
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