DC/Maryland Breastfeeding-Friendly Healthcare Provider Office Recognition Awards
Nomination/Site Inspection Form 2021
Sign in to Google to save your progress. Learn more
Email *
Healthcare Provider Office Name *
Office Address: *
Nominator (first and last name) *
Contact Person (Office Manager or Human Resource Manager) *
Contact Person E-mail Address *
Phone Number *
Size of Business *
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)
Silver (2 Points each)
Gold (3 Points each)
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.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of D.C. Breastfeeding Coalition. Report Abuse