Breastfeeding Friendly Workplace Award Nomination

Company Information:

Company Contact Person:
*Company Name:
# of Employees:
*First Name:
*Last Name:
*Address:
*City, State, Zip:
Email:
Phone #:
Fax #:
Person who is nominating the company:
*First Name:
*Last Name:
Position:
*Email:

Additional Information:

Please select the appropriate response regarding your organization

If you have questions please feel free to call Heidi Burke-Pevney at 760-443-8683
or Dr. Eyla Boies at 858-496-4825.

Submit Application

The Company provides information and resources about the benefits of breastfeeding: Yes No
Please list any specific examples:
Before maternity leave, the Company informs employees of their option to breastfeed and/or pump during working hours: Yes No
Please list any specific examples:
The Company provides a sink for hand washing & cleaning of breast milk collection devices: Yes No
Please list any specific examples:
The Company provides hygienic storage options for expressed breast milk: Yes No
Please list any specific examples:
The Company provides adequate time and flexibility for breastfeeding or pumping: Yes No
Please list any specific examples:
The Company offers prenatal or postpartum classes on breastfeeding to employees: Yes No
Please list any specific examples:
The Company offers Lactation Consultant services: Yes No
Please list any specific examples:
The Company has on-site day care so employees can breastfeed during breaks: Yes No
Please list any specific examples:
The Company has a written policy explaining the options and accommodations for expressing breast milk: Yes No
If YES, please upload a copy here: or email: wightsd@aol.com
The Company provides a private, comfortable and accessible location for expressing breast milk: Yes No
Please list any specific examples:
The lactation room has the following features (please check all that apply):
Locking door Privacy (window coverings, etc.) Sink Comfortable seating Resource materials A company provided multi-user pump Refrigerator or cooler Electricity or batteries provided Other supplies (such as hand sanitizer or wipes)	Other supplies:
Please use this additional space to include any information, such as a personal story, anecdotal reports and/or testimonials, that helps support your nomination.

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