CT Breastfeeding Coalition's Breastfeeding Friendly Employer Application
Thank you for supporting your employees and helping us to promote, protect and support breastfeeding in Connecticut! Please take a minute to answer the following questions so we may recognize your efforts to create a breastfeeding friendly work environment! If you have any difficulties or questions you can contact us by email:
info@breastfeedingct.org
About the Employer/Worksite/Organization
Name *
Mailing Address *
Phone Number *
Website
Type of Employer/Worksite/Organization *
Number of Employees *
List locations where your employee lactation support policy is being followed if more than the official address listed above:
Primary Contact Person for the Employee Lactation Support Program/Policy
First & Last Name *
Job Title/Position *
E-Mail *
Phone Number *
Employee Lactation Supports Provided
Employers must provide these three supports at a minimum to qualify for the recognition.
1. Does your business/worksite/organization have an accessible, private space (NOT a bathroom, is shielded from view of public and co-workers, is protected from intrusion) that an employee may use to breastfeed or express/pump breast milk? *
2. Does your business/worksite/organization provide employees flexible paid or unpaid break times to express/pump breast milk? *
3. Policy describing how your organization ensures all employees are able to access the above supports. Please email your employee breastfeeding policy to info@breastfeedingct.org.


If you would like any assistance, the CT Breastfeeding Coalition is here to help! Contact us info@breastfeedingct.org or www.breastfeedingct.org. The following links may be helpful if your organization does not currently have a policy: https://www.womenshealth.gov/supporting-nursing-moms-work https://www.womenshealth.gov/breastfeeding/breastfeeding-
home-work-and-public/breastfeeding-and-going-back-work/business-case
Other supports. Please check any additional workplace supports provided by your business/worksite/organization.
Check all that apply
I give the Connecticut Breastfeeding Coalition permission to:
Please send us any lactation space or employee support photos that your organization agrees to share on the CBC or It's Worth It websites. You can email them to info@breastfeedingct.org THANK YOU!
Submit
Never submit passwords through Google Forms.
This form was created inside of Connecticut Breastfeeding Coalition. Report Abuse