Breastfeeding-Friendly Workplace Recognition Awards Nomination Form


Business Information

* Business Name: 
Address: 
City: 
State:    Zip: 
* Contact Person: 
* Phone Number: 
* Email Address: 

Business Size:  Small (up to 50 employees)
Medium (51-499 employees)
Large (500+ employees)

* Name of nominator: 

Choose one: Employee
Company Representative

Email to receive confirmation of nomination (optional)  

Please add any additional information about your site, which you think would be helpful for us to know:
(max 3000 characters)

This company has agreed to have a worksite visit conducted.

(Required for submission)



Check all that apply:
  Bronze Silver Gold
Support Verbal agreement between mother and her direct supervisor regarding her break times and space to pump. Written breastfeeding support policy and/or mandatory guidelines.

Education/training about breastfeeding support policy/guidelines provided for managers/supervisors.

Bulletin board for mom-to-mom sharing in lactationkarea.
Mom-to-mom breastfeeding support group available.

Education/training about breastfeeding support policy/guidelines provided for all employees.

Posting/publication of policy for all to view.

Policy contains information pertaining to:
  • Discrimination
  • Flexible Breaks
  • Non-bathroom space to pump
Time Flexible breaks (at least 15-20 minutes in the morning and afternoon as well as a lunch break) during which the employee can express milk or nurse their infants.

Unpaid leave.
Ability to work part-time.

Telecommuting option.

Job-sharing offered.

Flex-time offered.

Compressed work week option.
Paid maternity leave (6+ weeks). Note: This doesn't include employees using accrued sick leave, vacation, FMLA or disability unless the company provides extra leave to compensate them.

On-site childcare. This can be a location with which the employer has an arrangement, if not company provided, where an employee can nurse her child during the work day.
Education Provides lists of local breastfeeding resources (HR or Occupational Health Department or web-based).

Provides educational packets/materials about breastfeeding for all expectant parents.
Provides onsite classes (in-person or web-based):
  • Pre-natal
  • Back to work

Lending library of breastfeeding resources.
Contract with International Board Certified Lactation Consultant (IBCLC) to provide one-on-one consults for employees paid by employer
  • Pre-natal consults
  • Post-partum consults during maternity leave
  • Back to work consults
Place Private area shielded from intrusion with a chair and small table, access to electricity and a nearby working sink.

Ability for employee to post "Do Not Disturb" sign while area in use.
Floating/multipurpose room with door available for use.

Electrical outlet located in room.

Comfortable chair in room.

Wall clock in room.

Refrigerator available for breastmilk storage.
Designated private room for pumping/breastfeeding.

Employer-provided multi-user pump available.

Employer-provided personal-use pumps available.

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