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:
About the Employer/Worksite/Organization
Type of Employer/Worksite/Organization
Accomidation & Food Services
Admin & Support Service
Agriculture, Forestry, Fishing & Hunting
Arts, Recreation & Entertainment
Child Care (CBC also has a separate Child Care recognition)
Finance & Insurnace
Healthcare & Social Assistance
Management & companies of Enterprise
Personal & Laundry Servies
Profesional, Scientific & Technical
Real Estate, Retail & Leasing Services
Religious, Grant Making, Civic, Professional & Similar Orginizations
Repair & Maintenance
Transportation & Wearhousing
Waste Management &Remediation Services
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
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 email@example.com.
If you would like any assistance, the CT Breastfeeding Coalition is here to help! Contact us
. The following links may be helpful if your organization does not currently have a policy:
Other supports. Please check any additional workplace supports provided by your business/worksite/organization.
Check all that apply
Small table near electrical outlet
Refrigerator for breastmilk storage
Sink for cleaning of equipment (other than shared kitchen or restroom)
Breast pump provided by employer or insurer
Reference Library (books or articles)
Listing of breastfeeding resources
Flex time or job sharing option
Lactation consultant services provided
Education for pregnant and breastfeeding employees (written)
Education for pregnant and breastfeeding women (formal classes)
I give the Connecticut Breastfeeding Coalition permission to:
List Business Information
List Website URL
Share Photos of Worksite Lactation Space
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 firstname.lastname@example.org THANK YOU!
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This form was created inside of Connecticut Breastfeeding Coalition.