Initial Breastfeeding Friendly Workplace Application

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 Name *

Workplace Address (must be located in Brown County)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Workplace Type (e.g. retail, office, healthcare)*

Number of Employees *

Approximate percentage of employees who are women of child-bearing ages 15-44*

Primary Contact Person *

First NameLast Name

Contact Person Title/Position*

Contact Email *

example@example.com

Contact Phone Number*

Please enter a valid phone number.

Preferred Method of Contact*

Phone CallText MessageEmailOther

Workplace provides opportunities for breastfeeding employees to receive support and encouragement. (Examples: message board, internal workplace support groups, information about local breastfeeding supports)*

YesNoPlanning to implementOther

Optional: Upload a list of local breastfeeding resources (local La Leche League chapter, lactation consultants, breastfeeding coalition, support groups) that is provided to pregnant and breastfeeding employees seeking breastfeeding information and support.

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.*

YesNoSomewhatOther

Education

Workplace ensures that all employees are familiar with the employer’s breastfeeding policy.*

YesNoSometimesOther

If yes, how do you ensure that all employees are familiar with the breastfeeding policy?

Employees are referred/educated on community resources when requested.*

YesNoSometimesOther

All supervisors are trained to support breastfeeding (i.e. aware of policy and resources for employees).*

YesNoSometimesOther

If yes, how are supervisors trained to support breastfeeding?

Policy

Does your workplace have a written policy or guideline that addresses the elements of support, time, education, and space outlined?*

YesNoPlanning to create one

If yes, please upload a copy of your breastfeeding policy

Information about the breastfeeding policy and workplace lactation support is provided to employees at the time of hire and when they request parental leave.*

YesNoSometimesOther

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?*

YesNoPlanning to create one

If yes, what features does the lactation space have?

Accessible Location (conveniently located near employee's work area, easy to reach, private, and available when needed)Privacy: locking door, privacy screen, or signageComfortable ChairAccess to Electrical Source: electrical outlet, generator, or battery packSmall Table or SurfaceHave or Be Near a Clean Refrigerator (for storing breastmilk)Have or Be Near Running Water (i.e. sink, a place to wash hands and clean pump equipment)Not a Bathroom

Please list here anything else you would like us to know about your lactation space(s)

If yes, please upload a photo of lactation space(s)

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?*

YesNo

How did you hear about this program? *

Any other comments?

Breastfeeding Friendly Workplace Initial Application

Workplace Information

Contact Person

STEPS for Breastfeeding Friendly Businesses

Support

Final Questions