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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?
f9863a92e9fe489fbe518cfddf9646d7 18-24 
f9863a92e9fe489fbe518cfddf9646d7 25-34 
f9863a92e9fe489fbe518cfddf9646d7 35-44 
f9863a92e9fe489fbe518cfddf9646d7 45-54 
f9863a92e9fe489fbe518cfddf9646d7 55-64 
f9863a92e9fe489fbe518cfddf9646d7 65-74 
f9863a92e9fe489fbe518cfddf9646d7 75 years and older 
How do you identify?
f9863a92e9fe489fbe518cfddf9646d7 Male 
f9863a92e9fe489fbe518cfddf9646d7 Female 
f9863a92e9fe489fbe518cfddf9646d7 Transgender 
f9863a92e9fe489fbe518cfddf9646d7 Genderqueer 
f9863a92e9fe489fbe518cfddf9646d7 Other 
What is your race / ethnicity?
Select all that apply
4f0c2b8710ed450190fdeeac9463f572 Black/African 
4f0c2b8710ed450190fdeeac9463f572 Hispanic/Latino/Latinx 
4f0c2b8710ed450190fdeeac9463f572 White/Caucasian 
4f0c2b8710ed450190fdeeac9463f572 American Indian 
4f0c2b8710ed450190fdeeac9463f572 Asian 
4f0c2b8710ed450190fdeeac9463f572 Other 
What is your primary language(s) spoken?
4f0c2b8710ed450190fdeeac9463f572 English 
4f0c2b8710ed450190fdeeac9463f572 Other 
4f0c2b8710ed450190fdeeac9463f572 Spanish 
4f0c2b8710ed450190fdeeac9463f572 Arabic 
4f0c2b8710ed450190fdeeac9463f572 French 
4f0c2b8710ed450190fdeeac9463f572 Gujarati 
4f0c2b8710ed450190fdeeac9463f572 Haitian Creole 
4f0c2b8710ed450190fdeeac9463f572 Hindi 
4f0c2b8710ed450190fdeeac9463f572 Italian 
4f0c2b8710ed450190fdeeac9463f572 Mandarin 
4f0c2b8710ed450190fdeeac9463f572 Polish 
4f0c2b8710ed450190fdeeac9463f572 Portuguese 
4f0c2b8710ed450190fdeeac9463f572 Tagalog 
Public Hearing Location
4f0c2b8710ed450190fdeeac9463f572 Wednesday, November 2- Rutgers Camden - Campus Center Multipurpose Room, 326 Penn St., Camden, NJ 08102 - 4:30 - 8:00PM 
4f0c2b8710ed450190fdeeac9463f572 Wednesday, November 9- Rutgers Newark - Rutgers New Jersey Medical School, Lecture Hall B552, 185 South Orange Ave., Newark, NJ 07103 - 4:30 - 8:00PM 
4f0c2b8710ed450190fdeeac9463f572 Saturday, December 3- DCF Training Academy, 30 Van Dyke Ave., New Brunswick, NJ 08901 - 10:00 - 1:00pm 
4f0c2b8710ed450190fdeeac9463f572 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
f9863a92e9fe489fbe518cfddf9646d7 No 
f9863a92e9fe489fbe518cfddf9646d7 Yes