Breastfeeding-Friendly Health Care Provider Office Recognition Awards Nomination Form

Practice Information

 State:   Zip: 
Contact Person: 
Phone Number: 
Email Address: 

Size of Practice:  Small (up to 15 employees)
Medium (15-30 employees)
Large (30+ employees)

Practices will be recognized as follows: Bronze Award: 5-10 points
Silver Award: 11-15 points
Gold Award: 15+ points AND
 at least 2 gold criteria must be met

Check all that apply:
Bronze (1 Point each) Silver (2 Points each) Gold (3 Points each)
Display non-commercial posters, pamphlets, pictures, and photographs of breastfeeding mothers in your office.

Display signs in the waiting area encouraging mothers to breastfeed.

Have available appropriate educational resources for parents (handouts, pictures, books, DVDs, websites).

Maintain a list of community breastfeeding resources

Have a written breastfeeding friendly office policy.

Have a nursing nook and/or private area shielded from intrusion for patients to use while nursing.
If providing antenatal care for the mother, introduce the subject of infant feeding in the first trimester and continue to express support of breastfeeding throughout the course of the pregnancy. (must be noted in medical record)

If providing postnatal care: schedule has protected visit slots to allow a first follow-up visit within 48 hours of discharge.

If providing postnatal care: a demonstrable system in place to automatically prescribe vitamin D to infants per AAP protocol.

Encourage breastfeeding mothers to feed newborns only human milk and to avoid offering supplemental formula, glucose water or other liquids unless medically necessary (must be noted in medical record).

Advise the mother not to offer a bottle or a pacifier until breastfeeding is well established (must be noted in medical record).

Evidence of a working relationships with lactation specialists in your community to make referrals as needed.
Office/staff does not distribute free formula and/or baby items from formula companies to parents.

If providing antenatal care: help pregnant women create a birth plan including breastfeeding, skin-to-skin, and rooming-in. (must provide sample/evidence).

Develop and follow telephone triage protocols to address breastfeeding concerns and problems. (must provide sample/evidence)

Office/staff conducts follow-up phone calls to assist breastfeeding mothers. (must provide sample/evidence)

Lactation Specialist (IBCLC, CLC or peer counselor) on staff

Prenatal breastfeeding class and/or support group offered in the office

Postnatal breastfeeding class and/or support group offered

Office/staff knowledgeable about the use of breast pumps and how to prescribe them through insurance (must provide sample/evidence).

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