Office Received
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Site ID
Minnesota Breastfeeding Friendly Maternity Center Designation
STEP 1 Application
To apply for completion of STEP 1:
Complete this form electronically using Adobe Acrobat or Adobe Reader 10.0 or later.
Save this PDF form to your computer and submit by email as an attachment to
[email protected], along with the Cover Sheet, any supporting documentation,
and the other applications for additional steps that your facility has completed. See the
Application Instructions on the MDH web page for more details.
Note: When asked to attach a document or enter text, it is acceptable to provide a link to
a current web page. An attachment is also an acceptable alternative to entering text
directly on this form. For all attachments, provide a file name and a brief description in
the Supporting Documents Table at the end of this application form.
STEP 1: Have a written breastfeeding policy that is routinely communicated to all
health care staff.
The health care facility has a written breastfeeding or infant feeding policy that addresses
all Ten Steps to Successful Breastfeeding. The policy includes the protection of
breastfeeding through adhering to the International Code of Marketing of Breastmilk
Substitutes. The policy prohibits the distribution of gift packs that contain samples,
coupons or promotional materials for breast milk substitutes, feeding bottles or nipples.
All human milk substitutes and infant feeding supplies are purchased in the same manner
as all other health care products, in accordance with fair market pricing. The facility
protects breastfeeding by prohibiting materials that recommend, endorse or imply
endorsement of feeding breast milk substitutes, scheduled feeds or other inappropriate
practices from being distributed to mothers.
The policy is available so that all staff who care for mothers and infants can refer to it. A
summary of the policy is available in the language(s) most commonly understood by
mothers, staff, and visitors.
The Ten Steps to Successful Breastfeeding and the International Code of Marketing of
Breastmilk Substitutes are written and displayed in the language(s) most commonly
understood by mothers, staff, and visitors and are displayed in all areas of the facility that
serve pregnant women, mothers, infants, and children, including:
• maternity care center (birthing rooms, triage rooms, consultation rooms, family
waiting rooms, all infant areas including special care nursery / NICU)
• pediatric units
• prenatal care clinics / in-patient units
• emergency department, radiology, admitting, nutrition therapy
NOTE: Facilities that are interested in pursuing designation from Baby-Friendly USA, Inc.
should refer to their specific guidelines and criteria here.
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1.1 Does the facility have a written breastfeeding/infant feeding
policy that promotes breastfeeding as the standard for infant feeding
and addresses all Ten Steps to Successful Breastfeeding?
If yes, include a copy of the breastfeeding/infant feeding policy/policies.
Yes
No
Yes
No
Yes
No
1.4 Is a summary of the breastfeeding / infant feeding policy available
for those requesting to read it?
Yes
No
1.5 a. Does the facility receive free formula or infant feeding supplies
from human milk substitute manufacturers or their representatives?
Yes
No
1.2 Is the breastfeeding/infant feeding policy:
a. Actively communicated to all staff within 6 months of hire?
b. How is it communicated? (Check all that apply)
Orientation Materials
Newsletters
Orientation Presentation
Staff Meetings
Competency Assessment
Other - Specify Below:
Provide written documentation for each method.
1.3a Are the Ten Steps to Successful Breastfeeding and the
International Code of Marketing of Breastmilk Substitutes written and
displayed in the language(s) most commonly understood by mothers,
staff and visitors?
b. Where are they displayed?
b. If the facility purchases its formula and infant feeding supplies, how was a fair
market price determined?
Note: Facilities that pursue designation from Baby-Friendly USA, Inc will be asked to provide a
copy of the purchasing agreement for formula and feeding supplies as part of their BabyFriendly application.
Community Cost Assessment
Internal Cost Analysis
Cooperative Agreement
Formulary Pricing
Quote from Company Representative
Other - Specify Below:
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STEP 1: Supporting Documents Table
File Name
Brief Description
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