Initial Breastfeeding Friendly Workplace Application

  • Breastfeeding Friendly Workplace Initial Application

  • Image field 63

  • Thank you for your interest in becoming a Breastfeeding Friendly Workplace! This initiative is designed to help businesses create a supportive environment for nursing parents by offering resources, guidance, and support. Please fill out the form below to express your interest in completing the program. We look forward to collaborating with you to create a supportive environment for nursing employees. 

    Please contact Becky, public health nurse with Brown County Public Health with any questions: 920-448-6435,  Becky.Mooren@browncountywi.gov 

    Adapted from the Minnesota Breastfeeding Friendly Workplaces

  • Workplace Information

  • Contact Person

  • Format: (000) 000-0000.
  • Preferred Method of Contact*

  • STEPS for Breastfeeding Friendly Businesses

    Support, Time, Education, Policy, Space

  • Support

  • Workplace provides opportunities for breastfeeding employees to receive support and encouragement. (Examples: message board, internal workplace support groups, information about local breastfeeding supports)*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Time 

  • Workplace provides work schedule and work pattern flexibility to accommodate reasonable break times for breastfeeding employees to express milk or breastfeed as needed, for 1 year or longer after the child’s birth.*

  • Education

  • Workplace ensures that all employees are familiar with the employer’s breastfeeding policy.*
  • Employees are referred/educated on community resources when requested.*
  • All supervisors are trained to support breastfeeding (i.e. aware of policy and resources for employees).*

  • Policy

  • Does your workplace have a written policy or guideline that addresses the elements of support, time, education, and space outlined?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Information about the breastfeeding policy and workplace lactation support is provided to employees at the time of hire and when they request parental leave.*

  • Space

    To be recognized as a Breastfeeding Friendly Workplace, employers must provide an appropriate number of lactation spaces relative to the number of breastfeeding employees.*

    Each lactation space must:

    • Be in an accessible location.
    • Be a private space, other than a bathroom, that is shielded from view and free from intrusion by coworkers and the public.
    • A locking door is ideal. If a locking door is not provided, please explain how you ensure privacy. (federal law)
    • Include access to an electrical outlet. 
    • Include a comfortable chair.
    • Include a small table or surface to support pumping equipment.
    • Have or be located near clean refrigerator space for milk storage.
    • Have or be located near a place to wash hands and clean pump equipment.

    *The appropriate number of lactation rooms depends on the size of the company, the number of female employees of childbearing age, and the number of buildings. Multiple sites should be provided if a site is not accessible for certain employees. Companies may wish to create lactation “suites,” installing partitions or curtains in the lactation room to accommodate multiple users at one time.

  • Does your workplace have a designated private space for employees to express breast milk?*
  • If yes, what features does the lactation space have?
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Final Questions

  • Are you willing to participate in the ongoing intervention for breastfeeding employees, including sharing the employee toolkit with your employees, annual surveys, and program evaluation?*
  • Should be Empty: