Application for Recognition as a
To Apply:
Breastfeeding Friendly Health Department:
Cover Sheet
Fill out this cover sheet and the individual applications for each step you have completed. Complete this form
electronically using Adobe Acrobat or Adobe Reader 9.1 or later. Adobe Reader is a free application that can be
downloaded from the internet. Save the form to your computer and submit it by email as an attachment to
[email protected], along with any other required attachments. Applications are accepted at any time but are
reviewed once annually. Submit an application by July 15th for review by September 15th that year. Contact
[email protected] with any questions.
Health Department Information:
Department Name
Department Address
City
State: MN
Zip Code
County
Contact Person 1
Name
Title
Email
Phone No.
Contact Person 2 (optional)
Name
Title
Email
Phone No.
Application:
My health department is applying for:
Bronze Level recognition - recognition for completion of Step One, Step Two, and any three additional steps
Silver Level recognition - recognition for completion of Step One, Step Two, and any five additional steps
Gold Level recognition - recognition for completion of all ten steps
Applications for the following steps are attached:
Steps 1 & 2
Step 3
Step 4
Step 5
Office Use:
Step 7
Step 8
Step 9
Step 10
Received
Filed
Site ID
Minnesota Department of Health
Office of Statewide Health Improvement Initiatives
P.O. Box 64882, St. Paul MN 55164-0882
www.health.mn.state.us/divs/oshii
Step 6