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Business Name
Street Address
Address Line 2
City
State/Province/Region
Postal/ZipCode
Parish
Website

Contact Name

First
Last
Contact Title
Contact Phone Number
How Many People Does Your Business Employ?
What percent of your employees are women between the ages of 15 and 44?
Please indicate the number of physical sites within your organization that are covered in this application. Please list them in the comment box below.
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In order to be designated as a “Breastfeeding-Friendly Workplace,” your business must have the following:

1. A person or a department to manage the lactation program.

Their Name

First
Last
Their Title
2. Reasonable break time for working mothers to pump breast milk each time they need to throughout the day
3. One or more permanent breastfeeding rooms, or there is a clean, private, and safe space with an outlet, other than a toilet stall that mothers can use for lactation when needed
4. A working sink near the breastfeeding location where mothers can clean pumping equipment (if this is not possible, please explain in the box below)
5. The lactation support (a place to pump and break time) is communicated to all current and future employees

If your workplace meets all of the requirements listed above, it will be designated as a "Breastfeeding-Friendly Workplace". If it meets these requirements, and also has a written policy to support breastfeeding, it will be designated as a "Breastfeeding-Friendly Workplace Champion".

Does your workplace have a written policy to support workplace lactation that meets minimum federal law requirements?
How did you hear about the Workplace Breastfeeding Support Program?
If you selected "Other", please explain:
Would you like a "Do Not Disturb: Pumping In Progress" door hanger sent to you? (A picture of it is at the bottom of the previous webpage.) If yes, how many would you like?
Does your management team need additional help with learning how to improve breastfeeding support? What can we do to help you?
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Additional Comments
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Upload your Workplace Policy, images of your Lactation Space, or anything else you feel is applicable (not required).Allowed files: pdf, doc, jpeg, png
Upload
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