DC/Maryland Breastfeeding-Friendly Workplace Recognition Awards
Nomination/Site Inspection Form 2021
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Nominator (first and last name)
Contact Person (Office Manager or Human Resource Manager)
Contact Person E-mail Address
Size of Business
Small (<50 employees)
Medium (50-500 employees)
Large (> 500 employees)
Check all criteria that you can verify:
Businesses will be recognized as follows:
Small (up to 50 employees): Bronze: 4-12 points, Silver 13-24 points, Gold ≥ 25 points (at least 1 gold criteria must be met)
Medium (50-500 employees): Bronze: 8-18 points, Silver 19-35 points (at least 1 silver criteria in 2 categories must be met), Gold ≥ 36 points (at least 2 gold criteria must be met)
Large (500+ employees): Bronze: 12-24 points, Silver 25-49 points (at least 1 silver criteria in each category must be met), Gold ≥ 50 points (at least 4 gold criteria from at least 2 different categories must be met)
Bronze (1 Point each)
[SUPPORT] Verbal agreement between employee and the employee’s direct supervisor regarding break times and space to pump.
[TIME] Flexible breaks (at least 15-20 minutes) during which employees can express milk or nurse their infants without work-related obligations.
[TIME] Unpaid leave for time used to express milk.
[EDUCATION] Provides lists of local breastfeeding resources (HR or Occupational Health Department or web-based).
[EDUCATION] Provides educational packets/materials about breastfeeding for all expectant parents.
[PLACE] Private area shielded from intrusion. Includes a chair and small table, access to electricity and a nearby working sink.
[PLACE] Ability for employee to post “Do Not Disturb” sign while area in use.
Silver (2 Points each)
[SUPPORT] Written breastfeeding support policy and/or mandatory guidelines.
[SUPPORT] Education/training about breastfeeding support policy/guidelines provided for managers/supervisors.
[SUPPORT] Bulletin board for employee-to-employee sharing in lactation area.
[TIME] Ability to work part-time.
[TIME] Telecommuting/Work from Home option.
[TIME] Job-sharing offered.
[TIME] Flextime offered.
[TIME] Compressed work week option.
[TIME] Employer offers paid pumping breaks.
[EDUCATION] Provides onsite classes (in-person or web-based): Prenatal / Back to work
[EDUCATION] Lending library of breastfeeding resources.
[PLACE] Floating/multipurpose room with door available for use.
[PLACE] Electrical outlet located in room.
[PLACE] Comfortable chair in room.
[PLACE] Wall clock in room.
[PLACE] Refrigerator available for breastmilk storage.
[PLACE] Mirror in room.
Gold (3 Points each)
[SUPPORT] Employee breastfeeding support group available.
[SUPPORT] Assistance with shipping milk home when traveling for work.
[SUPPORT] Education/training about breastfeeding support policy/guidelines provided for all employees.
[SUPPORT] Posting or publication of policy/mandatory guidelines for all to view.
[SUPPORT] Policy contains information pertaining to (must contain all 3): Discrimination / Flexible Breaks / Non-bathroom space to pump
[TIME] Paid maternity leave (not utilizing vacation and sick time)
[TIME] On-site childcare.
[EDUCATION] Employer provides access to a Lactation Support Provider to provide one-on-one consults for employees (paid by employer): Prenatal consults / Post-partum consults during maternity leave / Back to work consults
[PLACE] Designated private room used only for pumping/breastfeeding.
[PLACE] Employer-provided multi-user pump available.
[PLACE] Employer-provided personal-use pumps available.
[PLACE] Lockers or other locked area for employees to store breast pump and pumping supplies.
[PLACE] Additional pumping supplies available onsite.
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.