Breastfeeding Friendly Employer Recognition Award
About the person filling out this application:
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First Name
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Last Name
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Your Phone Number
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Your Email Address
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Person Filling Out this Application is
Owner of Company, Business or Agency
Supervisor of Company, Business or Agency
Human Resource Dept of Company, Business or Agency
Employee of Company, Business or Agency
A Private Individual
About the Company, Business or Agency being recommended for this Award:
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Name of Company, Business or Agency You are Recommending for this Award
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Street Address of Company, Business or Agency
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Florida City of Company, Business or Agency
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Zip Code of Company, Business or Agency
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Company, Business or Agency Contact Person Name (person to contact regarding this award)
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Company, Business or Agency Contact Person's Email
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Company, Business or Agency Contact Person's Phone
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Company, Business or Agency Contact Person's FAX
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Above Contact Person is
Owner of Company, Business or Agency
Supervisior of Company, Business or Agency
Human Resource Dept of Company, Business or Agency
Employee of Company, Business or Agency
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Check YES for each feature of breastfeeding support the Company, Business or Agency being recommended for this Award provides:
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NO
Verbal agreement between employee mother and her direct supervisior regarding her break times and space to pump.
Private area to pump other than a bathroom
Flexible break adequate for 15-20 pumping time
Written breastfeeding support policy
Education about policy provided to all employees
Comfortable chair for pumping and/or nursing
Small table provided in private room for pumping
Electrical outlet provided in private room for pumping
Refrigerator provided for breastmilk storage
Sink with running water provided for clean up after pumping
Paid maternity leave (6 weeks)
Educational packet about breastfeeding given to all expectant parents
Breast pump provided by employer
Wall clock in pumping room
Radio/CD player in pumping room
Telephone in pumping room
Breastfeeding wall art in pumping room
Ability for breastfeeding employees to work part-time or some hours from home
Flextime offered
Job-sharing offered
Onsite childcare
Maternity leave available for up to 12 weeks (6 weeks Paid)
Lending Library of Breastfeeding Resources
List of regional breastfeeding resources
Lactation consultant services provided for employees (via insurance or paid by employer)
The Florida Breastfeeding Coalition will be contacting the contact person in the next couple of weeks.
Thank you for your application and for supporting the breastfeeding feeding mothers in your employment.
Please click the SUBMIT button after completion of this form.
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