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Lactation Space User Agreement and Demographic Information
[HSEC
7-171
& PWB
2-242C]
Please complete this form so the Health Sciences Education Center has some information about those using the building’s lactation rooms and about the population being served by these spaces.
This form is for access to lactation spaces in
HSEC
7-171
& PWB
2-242C.
This information will be used when we need to communicate a change in keypad code (which will happen at the beginning of each year). Your information is confidential and only non-identifying information will be shared with others.
Please email hsecwellness@umn.edu with any questions.
* Indicates required question
Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Email
*
Your answer
University college or department (write N/A if not applicable)
*
Your answer
Home / Mobile / Campus Phone
Your answer
Relationship to University
*
Graduate/Professional Student
Undergraduate Student
Faculty
Staff
Other:
Date you expect to start using this space
*
MM
/
DD
/
YYYY
Approximate number of times per day you might use this room
*
Your answer
How did you hear about this room?
*
Wesbsite
Referral
Email Communication
Lactation Advisory Committee
Other:
Required
I agree to use the HSEC Lactation rooms according to the guidelines provided. I will report any problems with the equipment or space to AHS staff at
hsecwellness@umn.edu
as soon as possible so it can be addressed quickly. I will not give the keypad combination to anyone who has not completed this agreement. Rather, I will have them contact the above email to obtain the information.
*
I agree
Participant's signature (electronic signature okay)
*
Your answer
Today's Date
*
MM
/
DD
/
YYYY
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