Company Information:

Company Name:

Type of Business:

Number of Employees:

Contact Person: Telephone:

Fax Number: E-Mail Address:

Location(s) of Business:

Please answer the following questions:

  1. How does your business provide work schedule flexibility including scheduling breaks and work patterns to provide time for expression of breastmilk by employees who are breastfeeding? (Most moms will need approximately 30 minutes every 3 to 4 hours during the workday to express milk. These employees can add 15 minutes to their morning and afternoon breaks by shortening their lunches by 30 minutes or by arriving 15 minutes earlier to work and by leaving 15 minutes later.)

  2. How does your business provide a private, accessible location for expression of breastmilk? (Any clean private room with a locking door, electricity and a comfortable chair can function as breastpump room.)

  3. How does your business provide a clean, safe water source and a sink for handwashing and cleaning of breastmilk collection devices? (A nearby break area or restroom can be used)

  4. What type of hygienic storage options for pumped breastmilk are provided to breastfeeding employees? (A refrigerator, ice chest, or a cool safe area free from contamination may be used.) and how will the employee access these areas?

  5. Does a Policy and Procedure or Human Resource Document exist explaining that this is a Breastfeeding Friendly Business? (please provide a copy) How do you inform employees about your Worksite Lactation Program?
  6. Do you offer prenatal or postpartum classes on breastfeeding to employees or have a wellness program?
  7. Do you utilize the services of a Lactation Consultant?
  8. Do you have on site day care?

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