Breastfeeding-Friendly Workplace Recognition Awards Nomination Form

Business Information

* Business Name: 
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)  

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).

On-site childcare.
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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