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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?
6f46982536dc419a9a08dcd389386809 18-24 
6f46982536dc419a9a08dcd389386809 25-34 
6f46982536dc419a9a08dcd389386809 35-44 
6f46982536dc419a9a08dcd389386809 45-54 
6f46982536dc419a9a08dcd389386809 55-64 
6f46982536dc419a9a08dcd389386809 65-74 
6f46982536dc419a9a08dcd389386809 75 years and older 
How do you identify?
6f46982536dc419a9a08dcd389386809 Male 
6f46982536dc419a9a08dcd389386809 Female 
6f46982536dc419a9a08dcd389386809 Transgender 
6f46982536dc419a9a08dcd389386809 Genderqueer 
6f46982536dc419a9a08dcd389386809 Other 
What is your race / ethnicity?
Select all that apply
8e4403021119471ebf7528a7c3cbfad6 Black/African 
8e4403021119471ebf7528a7c3cbfad6 Hispanic/Latino/Latinx 
8e4403021119471ebf7528a7c3cbfad6 White/Caucasian 
8e4403021119471ebf7528a7c3cbfad6 American Indian 
8e4403021119471ebf7528a7c3cbfad6 Asian 
8e4403021119471ebf7528a7c3cbfad6 Other 
What is your primary language(s) spoken?
8e4403021119471ebf7528a7c3cbfad6 English 
8e4403021119471ebf7528a7c3cbfad6 Other 
8e4403021119471ebf7528a7c3cbfad6 Spanish 
8e4403021119471ebf7528a7c3cbfad6 Arabic 
8e4403021119471ebf7528a7c3cbfad6 French 
8e4403021119471ebf7528a7c3cbfad6 Gujarati 
8e4403021119471ebf7528a7c3cbfad6 Haitian Creole 
8e4403021119471ebf7528a7c3cbfad6 Hindi 
8e4403021119471ebf7528a7c3cbfad6 Italian 
8e4403021119471ebf7528a7c3cbfad6 Mandarin 
8e4403021119471ebf7528a7c3cbfad6 Polish 
8e4403021119471ebf7528a7c3cbfad6 Portuguese 
8e4403021119471ebf7528a7c3cbfad6 Tagalog 
Public Hearing Location
8e4403021119471ebf7528a7c3cbfad6 Wednesday, November 2- Rutgers Camden - Campus Center Multipurpose Room, 326 Penn St., Camden, NJ 08102 - 4:30 - 8:00PM 
8e4403021119471ebf7528a7c3cbfad6 Wednesday, November 9- Rutgers Newark - Rutgers New Jersey Medical School, Lecture Hall B552, 185 South Orange Ave., Newark, NJ 07103 - 4:30 - 8:00PM 
8e4403021119471ebf7528a7c3cbfad6 Saturday, December 3- DCF Training Academy, 30 Van Dyke Ave., New Brunswick, NJ 08901 - 10:00 - 1:00pm 
8e4403021119471ebf7528a7c3cbfad6 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
6f46982536dc419a9a08dcd389386809 No 
6f46982536dc419a9a08dcd389386809 Yes 
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