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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?
168ca0515fa8455c9e6a75d70d2fc725 18-24 
168ca0515fa8455c9e6a75d70d2fc725 25-34 
168ca0515fa8455c9e6a75d70d2fc725 35-44 
168ca0515fa8455c9e6a75d70d2fc725 45-54 
168ca0515fa8455c9e6a75d70d2fc725 55-64 
168ca0515fa8455c9e6a75d70d2fc725 65-74 
168ca0515fa8455c9e6a75d70d2fc725 75 years and older 
How do you identify?
168ca0515fa8455c9e6a75d70d2fc725 Male 
168ca0515fa8455c9e6a75d70d2fc725 Female 
168ca0515fa8455c9e6a75d70d2fc725 Transgender 
168ca0515fa8455c9e6a75d70d2fc725 Genderqueer 
168ca0515fa8455c9e6a75d70d2fc725 Other 
What is your race / ethnicity?
Select all that apply
8cfc6ac451a74f7490804e6135c34291 Black/African 
8cfc6ac451a74f7490804e6135c34291 Hispanic/Latino/Latinx 
8cfc6ac451a74f7490804e6135c34291 White/Caucasian 
8cfc6ac451a74f7490804e6135c34291 American Indian 
8cfc6ac451a74f7490804e6135c34291 Asian 
8cfc6ac451a74f7490804e6135c34291 Other 
What is your primary language(s) spoken?
8cfc6ac451a74f7490804e6135c34291 English 
8cfc6ac451a74f7490804e6135c34291 Other 
8cfc6ac451a74f7490804e6135c34291 Spanish 
8cfc6ac451a74f7490804e6135c34291 Arabic 
8cfc6ac451a74f7490804e6135c34291 French 
8cfc6ac451a74f7490804e6135c34291 Gujarati 
8cfc6ac451a74f7490804e6135c34291 Haitian Creole 
8cfc6ac451a74f7490804e6135c34291 Hindi 
8cfc6ac451a74f7490804e6135c34291 Italian 
8cfc6ac451a74f7490804e6135c34291 Mandarin 
8cfc6ac451a74f7490804e6135c34291 Polish 
8cfc6ac451a74f7490804e6135c34291 Portuguese 
8cfc6ac451a74f7490804e6135c34291 Tagalog 
Public Hearing Location
8cfc6ac451a74f7490804e6135c34291 Wednesday, November 2- Rutgers Camden - Campus Center Multipurpose Room, 326 Penn St., Camden, NJ 08102 - 4:30 - 8:00PM 
8cfc6ac451a74f7490804e6135c34291 Wednesday, November 9- Rutgers Newark - Rutgers New Jersey Medical School, Lecture Hall B552, 185 South Orange Ave., Newark, NJ 07103 - 4:30 - 8:00PM 
8cfc6ac451a74f7490804e6135c34291 Saturday, December 3- DCF Training Academy, 30 Van Dyke Ave., New Brunswick, NJ 08901 - 10:00 - 1:00pm 
8cfc6ac451a74f7490804e6135c34291 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
168ca0515fa8455c9e6a75d70d2fc725 No 
168ca0515fa8455c9e6a75d70d2fc725 Yes 
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