EmailMe Form - Breastfeeding Friendly Employer Award Application

Name of Company, Business or Agency *

Your Name *

First Last

Your Phone

### - ### - ####

Your Email *

Person Filling Out this Application is *

Owner of Company, Business or Agency

Supervisor of Company, Business or Agency

Human Resource Dept of Company, Business or Agency

Employee of Company, Business or Agency

A Private Individual

Name of BEST Contact Person regarding this application at the Company, Business or Agency *

Contact Person's phone number *

Contact Person's fax number *

Contact Person's email *

Address of Company, Business or Agency applying for this award *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Please check the appropriate answer for each feature of breastfeeding support the Company, Business or Agency being recommended for this Award provides: *

	YES	NO
Written breastfeeding support policy
Verbal agreement between employee mother and her direct supervisior regarding her break times and space to pump
Private area to pump other than a bathroom
Flexible break adequate for 15-20 pumping time
Education about policy provided to all employees
Comfortable chair for pumping and/or nursing
Small table provided in private room for pumping
Electrical outlet provided in private room for pumping
Refrigerator provided for breastmilk storage
Sink with running water provided for clean up after pumping
Paid maternity leave (6 weeks)
Educational packet about breastfeeding given to all expectant parents
Breast pump provided by employer
Wall clock in pumping room
Radio/CD player in pumping room
Telephone in pumping room
Breastfeeding wall art in pumping room
Ability for breastfeeding employees to work part-time or some hours from home
Flextime offered
Job-sharing offered
Onsite childcare
Maternity leave available for up to 12 weeks (6 weeks Paid)
Lending Library of Breastfeeding Resources
List of regional breastfeeding resources
Lactation consultant services provided for employees (via insurance or paid by employer)

Describe any obstacles you had in accommodating your breastfeeding employees and how you creatively overcome those obstacles

Thank you for your application and for supporting the breastfeeding mothers in your employment. Please click the SUBMIT button after completion of this form.

You will receive an email from the Business Case for Breastfeeding Committee within 2 weeks.