DC/Maryland Breastfeeding-Friendly Healthcare Provider Office Recognition Awards
Nomination/Site Inspection Form 2021
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Healthcare Provider Office Name
Nominator (first and last name)
Contact Person (Office Manager or Human Resource Manager)
Contact Person E-mail Address
Size of Business
Small (up to employees)
Medium (15-30 employees)
Large (30+ employees)
Check all criteria that you can verify:
Practices will be recognized as follows:
Bronze Award: 10-16 points
Silver Award: 17-24 points
Gold Award ≥ 25 points (at least 2 gold criteria must be met)
Bronze (1 Point each)
Display posters, pamphlets, pictures, and photographs of breastfeeding parents and children in your office.
Display signs in the waiting area encouraging parents to breastfeed.
Provide educational resources about breastfeeding to parents that are objective, do not include infant formula advertising, and are not from any formula company. These can include handouts, pictures, books, DVDs, and/or websites.
Maintain and refer to a list of community breastfeeding resources.
Have a written breastfeeding-friendly office policy.
Have a nursing nook and/or private area shielded from intrusion for patients to use while nursing, if desired. Allow and encourage nursing in waiting rooms and patient care areas if comfortable doing so.
Silver (2 Points each)
If providing antenatal care: introduce the subject of infant feeding in the first trimester and continue to express support and encouragement of breastfeeding throughout the course of the pregnancy (must be documented in the medical record).
If providing postnatal care: schedule has protected visit slots to allow a first follow-up visit within 48 hours of discharge.
If providing postnatal care: a demonstrable system in place to automatically prescribe vitamin D to infants per AAP protocol.
Encourage breastfeeding parents to feed newborns only human milk and to avoid offering supplemental formula, glucose water, or other liquids unless medically necessary (must be documented in the medical record).
Advise the parent not to offer a bottle or a pacifier until breastfeeding is well established (must be documented in the medical record).
Working relationships with lactation specialists in your community to make referrals as needed.
Breastfeeding peer counselor on staff.
No pictures/posters of bottles or babies fed with bottles are displayed in office.
Gold (3 Points each)
Office/staff does not distribute free formula and/or baby items from formula companies to parents.
If providing antenatal care: help patients create a birth plan including breastfeeding, skin-to-skin, and rooming-in (must provide sample/evidence).
Develop and follow telephone triage protocols to address breastfeeding concerns and problems (must provide sample/evidence).
Office/staff conducts follow-up phone calls to assist breastfeeding families (must provide sample/evidence).
Lactation Support Provider on staff.
Prenatal breastfeeding class and/or support group offered in the office.
Postnatal breastfeeding class and/or support group offered in the office.
Office/staff knowledgeable about the use of breast pumps and regularly prescribe them through insurance (must provide sample/evidence).
Please feel free to share any additional details about your breastfeeding supports.
A copy of your responses will be emailed to the address you provided.
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This form was created inside of D.C. Breastfeeding Coalition.