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Breastfeeding-Friendly Workplace Application
Business Name
Section 1
Street Address
Address Line 2
City
State/Province/Region
Postal/ZipCode
Country
Parish
Website
Section 2

Contact Name

First
Last
Contact Title
Contact Phone Number
Section 3
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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Section 4

In order to be designated as a “Breastfeeding-Friendly Workplace Champion,” your business must have the following:

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

Name of person that manages the lactation accommodations

First
Last
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
6. A written policy to support workplace lactation that meets minimum federal law requirements
Section 5
How did you hear about the Workplace Breastfeeding Support Program?
If you selected "Other", please explain:
Would you like a "Please Do Not Disturb" door hanger sent to you? See picture below. 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). Please also upload your workplace logo so that we can include it when we announce your workplace on social media or on any printed promotions.Allowed files: pdf, doc, jpeg, png
Upload
Section 6 - Breastfeeding Welcome Here Pledge
Do clients, patients, or customers (i.e. the general public) visit your worksite?

If you answered yes to the above question, you are eligible to commit to the following pledge and be recognized as a Breastfeeding Welcome Here establishment on the Louisiana Breastfeeding Coalition website.


Breastfeeding Welcome Here Pledge:

We will:

  • Provide a comfortable, supportive environment for mothers to nurse in our establishment
  • Ensure that all staff members are aware of the project
  • Display the Breastfeeding Welcome Here signage in a highly visible place
  • Provide lactation accommodations (time and space other than a restroom) for our employees
We will not:
  • Ask breastfeeding persons to leave the establishment to nurse
  • Ask breastfeeding persons to go to the restroom or a different area
  • Ask a breastfeeding person to cover-up or nurse discreetly
My workplace commits to the above pledge
Would you like a window cling or a cardstock sign to be sent to you? They both are 5 x 7 inches. See picture below.You may choose more than one of the following options. If you would like multiple clings or signs, please tell us in the additional comments box below.
Additional Comments
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