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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?
9256f7d094dd402e85d7011a722bfce6 18-24 
9256f7d094dd402e85d7011a722bfce6 25-34 
9256f7d094dd402e85d7011a722bfce6 35-44 
9256f7d094dd402e85d7011a722bfce6 45-54 
9256f7d094dd402e85d7011a722bfce6 55-64 
9256f7d094dd402e85d7011a722bfce6 65-74 
9256f7d094dd402e85d7011a722bfce6 75 years and older 
How do you identify?
9256f7d094dd402e85d7011a722bfce6 Male 
9256f7d094dd402e85d7011a722bfce6 Female 
9256f7d094dd402e85d7011a722bfce6 Transgender 
9256f7d094dd402e85d7011a722bfce6 Genderqueer 
9256f7d094dd402e85d7011a722bfce6 Other 
What is your race / ethnicity?
Select all that apply
0f8080195fc346a1a6dadea905ecd2a2 Black/African 
0f8080195fc346a1a6dadea905ecd2a2 Hispanic/Latino/Latinx 
0f8080195fc346a1a6dadea905ecd2a2 White/Caucasian 
0f8080195fc346a1a6dadea905ecd2a2 American Indian 
0f8080195fc346a1a6dadea905ecd2a2 Asian 
0f8080195fc346a1a6dadea905ecd2a2 Other 
What is your primary language(s) spoken?
0f8080195fc346a1a6dadea905ecd2a2 English 
0f8080195fc346a1a6dadea905ecd2a2 Other 
0f8080195fc346a1a6dadea905ecd2a2 Spanish 
0f8080195fc346a1a6dadea905ecd2a2 Arabic 
0f8080195fc346a1a6dadea905ecd2a2 French 
0f8080195fc346a1a6dadea905ecd2a2 Gujarati 
0f8080195fc346a1a6dadea905ecd2a2 Haitian Creole 
0f8080195fc346a1a6dadea905ecd2a2 Hindi 
0f8080195fc346a1a6dadea905ecd2a2 Italian 
0f8080195fc346a1a6dadea905ecd2a2 Mandarin 
0f8080195fc346a1a6dadea905ecd2a2 Polish 
0f8080195fc346a1a6dadea905ecd2a2 Portuguese 
0f8080195fc346a1a6dadea905ecd2a2 Tagalog 
Public Hearing Location
0f8080195fc346a1a6dadea905ecd2a2 Wednesday, November 2- Rutgers Camden - Campus Center Multipurpose Room, 326 Penn St., Camden, NJ 08102 - 4:30 - 8:00PM 
0f8080195fc346a1a6dadea905ecd2a2 Wednesday, November 9- Rutgers Newark - Rutgers New Jersey Medical School, Lecture Hall B552, 185 South Orange Ave., Newark, NJ 07103 - 4:30 - 8:00PM 
0f8080195fc346a1a6dadea905ecd2a2 Saturday, December 3- DCF Training Academy, 30 Van Dyke Ave., New Brunswick, NJ 08901 - 10:00 - 1:00pm 
0f8080195fc346a1a6dadea905ecd2a2 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
9256f7d094dd402e85d7011a722bfce6 No 
9256f7d094dd402e85d7011a722bfce6 Yes 
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