Mother-Baby Friendly Workplace
State Recognition Award
The California Breastfeeding Coalition will present the Mother-Baby Friendly Workplace
State Recognition Award May 7, 2015; 11AM at the State Capitol to employers who
support breastfeeding employees and have a written lactation support policy.
To nominate your local employers for this State Recognition Award, please do the
following:
 Complete the following nomination form for each employer (no more than three
nominations per coalition).
 Attach the employer’s written lactation support policy. They must have policy or
clear guidelines.
 Send a photo of the accommodations if possible.
 Send along any other supporting documentation.
 Submit the nomination form or complete the online form at
https://www.surveymonkey.com/r/BG238ND, policy, photo and any
supporting documents to Robbie Gonzalez-Dow at
[email protected] by Friday, April 3, 2015.
After the nomination form is received, we will contact you for follow-up. Depending on
your relationship with the employer, we may need you to assist with any clarifications
about their lactation support program. It is necessary that any employer you nominate
have a written lactation support policy or clear guidelines.
What is your contact information?
Contact Person’s Name: _________________________________________________
Local Coalition Name: ___________________________________________________
Phone Number: ________________________________________________________
E-mail: _______________________________________________________________
Tell us about who you are nominating:
Company Name: _______________________________________________________
Contact Person’s Name and Title: __________________________________________
_____________________________________________________________________
Mailing Address: _______________________________________________________
_____________________________________________________________________
Phone Number: ________________________________________________________
E-mail: _______________________________________________________________
1
Type of employer:
Number of employees:
Describe the private area to express breastmilk and/or to directly breastfeed. (attach
photo if possible)
Explain how breastmilk expression and/or breastfeeding break time is scheduled.
Describe any breastfeeding education and/or referrals given to employees.
2
List any breastfeeding equipment provided by employer.
How are the employees informed about the workplace lactation accommodations and
how do they access lactation accommodations at this company?
Does this company provide any training to supervisors on the lactation accommodation
benefits?
3
Are there any program impacts that have been documented, such as absenteeism,
retention, health care cost savings or loyalty?
Please provide any other information on why you believe this employer deserves state
recognition.
You can also complete this form online at https://www.surveymonkey.com/r/BG238ND.
If you have questions, please contact:
Robbie Gonzalez-Dow
[email protected] or at 831-917-8939
Please email the nomination form to
Robbie Gonzalez-Dow at [email protected]
by Friday, April 3, 2015
4