Office Received
Use
Filed
Only
Site ID
Minnesota Breastfeeding Friendly Maternity Center Designation
Application Cover Sheet
Fill out this Cover Sheet and the individual Step Application forms for each step that your
facility has completed. Complete all PDF forms electronically using Adobe Acrobat or Adobe
Reader 10.0 or later (free download available online). Save the forms to your computer and
submit them together by email as attachments to [email protected], along with any
supporting documentation. Submissions are accepted at any time, but are reviewed on a
semi-annual basis. Submit an application by May 31 or October 31 for review by the end of
the following month. Contact Linda Dech at [email protected] with any questions.
Maternity Center Information:
Facility Name (to be printed on certificate):
Mailing Address:
City:
State: MN
Zip Code:
Contact Information:
Name/Credentials:
Title:
Email:
Phone Number:
Application Type:
New Application
My facility is applying for:
Re-Designation (for additional stars)
Renewal (every 3 years)
1 Star Designation: for achieving two steps
2 Star Designation: for achieving four steps
3 Star Designation: for achieving six steps
4 Star Designation: for achieving eight steps
5 Star Designation: for achieving all ten steps
Applications for the following steps are attached (check all that apply):
Step 1
Step 2
Step 3
Step 4
Step 6
Step 7
Step 8
Step 9
Step 5
Step 10
Submission Authorization:
I acknowledge that the facility's CEO/COO is aware of the submission of this application
to the Minnesota Department of Health (MDH) appointed designation committee.
I consent to having the designation decision posted on the MDH public website.
Indicate the web address (URL) to link to the facility:
Minnesota Breastfeeding Friendly Maternity Center Designation
Optional: Information for Public Health Program Planning
Information collected on this page will in no way influence the determination of the facility’s
designation. This information will be used for public health program planning and is confidential.
Identification of Application Team Members:
Check all the persons in relevant positions included on your application team:
Maternity Center Administrator or Manager
Obstetrical Provider
Pediatric Provider
Family Medicine Provider
Other Relevant Staff-Specify Below
Nurse from Newborn Care
Night Maternity Nurse
Labor & Delivery Nurse
Lactation Consultant (IBCLC)
Lactation Consultant Staffing:
Number of Lactation Consultants (IBCLCs) currently on staff:
Number of IBCLC Full Time Equivalents:
Coverage Hours of IBCLCs:
Breastfeeding Data:
Collection Method:
On-going Basis
Exclusive Breastfeeding Rate* at Discharge:
Specific Time Period:
to
%
*no food or drink other than human milk
Overall Breastfeeding Rate** at Discharge:
%
**human milk with formula complement
How are the breastfeeding data
shared with maternity care staff?
Facility Programming:
Has your facility implemented the Joint Commission on Accreditation
of Healthcare Organizations (JCAHO) Perinatal Core Measure Set?
Yes
No
Does your facility intend on applying for Baby-Friendly designation
through Baby-Friendly USA, Inc.?
Yes
No
If yes, indicate anticipated time frame:
Submit by Email