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.
Email *
First Name *
Last Name *
Email *
University college or department (write N/A if not applicable)
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Home / Mobile / Campus Phone
Relationship to University
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Date you expect to start using this space *
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Approximate number of times per day you might use this room
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How did you hear about this room?
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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.
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Participant's signature (electronic signature okay)
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Today's Date *
MM
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DD
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YYYY
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