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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?
d64eaad9c447495887fd15ab4cf56628 18-24 
d64eaad9c447495887fd15ab4cf56628 25-34 
d64eaad9c447495887fd15ab4cf56628 35-44 
d64eaad9c447495887fd15ab4cf56628 45-54 
d64eaad9c447495887fd15ab4cf56628 55-64 
d64eaad9c447495887fd15ab4cf56628 65-74 
d64eaad9c447495887fd15ab4cf56628 75 years and older 
How do you identify?
d64eaad9c447495887fd15ab4cf56628 Male 
d64eaad9c447495887fd15ab4cf56628 Female 
d64eaad9c447495887fd15ab4cf56628 Transgender 
d64eaad9c447495887fd15ab4cf56628 Genderqueer 
d64eaad9c447495887fd15ab4cf56628 Other 
What is your race / ethnicity?
Select all that apply
bedaf0b392fa4ea0801ffa63d615f0b4 Black/African 
bedaf0b392fa4ea0801ffa63d615f0b4 Hispanic/Latino/Latinx 
bedaf0b392fa4ea0801ffa63d615f0b4 White/Caucasian 
bedaf0b392fa4ea0801ffa63d615f0b4 American Indian 
bedaf0b392fa4ea0801ffa63d615f0b4 Asian 
bedaf0b392fa4ea0801ffa63d615f0b4 Other 
What is your primary language(s) spoken?
bedaf0b392fa4ea0801ffa63d615f0b4 English 
bedaf0b392fa4ea0801ffa63d615f0b4 Other 
bedaf0b392fa4ea0801ffa63d615f0b4 Spanish 
bedaf0b392fa4ea0801ffa63d615f0b4 Arabic 
bedaf0b392fa4ea0801ffa63d615f0b4 French 
bedaf0b392fa4ea0801ffa63d615f0b4 Gujarati 
bedaf0b392fa4ea0801ffa63d615f0b4 Haitian Creole 
bedaf0b392fa4ea0801ffa63d615f0b4 Hindi 
bedaf0b392fa4ea0801ffa63d615f0b4 Italian 
bedaf0b392fa4ea0801ffa63d615f0b4 Mandarin 
bedaf0b392fa4ea0801ffa63d615f0b4 Polish 
bedaf0b392fa4ea0801ffa63d615f0b4 Portuguese 
bedaf0b392fa4ea0801ffa63d615f0b4 Tagalog 
Public Hearing Location
bedaf0b392fa4ea0801ffa63d615f0b4 Wednesday, November 2- Rutgers Camden - Campus Center Multipurpose Room, 326 Penn St., Camden, NJ 08102 - 4:30 - 8:00PM 
bedaf0b392fa4ea0801ffa63d615f0b4 Wednesday, November 9- Rutgers Newark - Rutgers New Jersey Medical School, Lecture Hall B552, 185 South Orange Ave., Newark, NJ 07103 - 4:30 - 8:00PM 
bedaf0b392fa4ea0801ffa63d615f0b4 Saturday, December 3- DCF Training Academy, 30 Van Dyke Ave., New Brunswick, NJ 08901 - 10:00 - 1:00pm 
bedaf0b392fa4ea0801ffa63d615f0b4 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
d64eaad9c447495887fd15ab4cf56628 No 
d64eaad9c447495887fd15ab4cf56628 Yes 
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