Lactation Room User Agreement
Please print or type clearly.
Name:
University ID #:
Campus (if applicable) or home address:
E-mail:
Phone:
Please initial each statement or set of statements.
I agree that it is my choice to use the Lactation Room(s) and any of the related items in the room(s) at IUPUC.
Steps will be taken to keep the room clean, safe, and secure, but I understand that others cannot be held liable
for the day-to-day condition of the room and its contents.
I agree that I am responsible for doing my part to keep the room I use clean and orderly. I understand that breast
milk is a body fluid and careful cleanup of spills, etc., is important. I will bring sanitizing wipes for that purpose.
Out of respect for the needs of other nursing mothers who need to access the space, I agree that access to the
lactation room is for my use only, and that sharing my access to the space with anyone else is not permitted. I
will only use the room while nursing or pumping, and I will secure the door after using.
I understand/agree that I am responsible for transportation and proper storage of milk and bringing my own
equipment, storage containers, and cooler. Resources for proper storage of breast milk are available at the following
link: http://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm. A hospital grade pump is
available for my use, but I must provide my own tubing and other supplies.
I understand that my use of these facilities is subject to space availability.
I understand that in order to ensure that only authorized persons use these rooms, my name may be shared with
the very limited number of university employees who are in charge of providing these facilities in various buildings
so that they know I have completed the User Agreement and, therefore, am authorized to use the rooms.
I agree to stop using the facilities when I am no longer nursing and/or pumping, will notify Carrie Shaver that I
no longer need the facilities, and my access will be terminated at that time.
I understand that upon submission of my signed form, the Office of Registrar Services will [students only: issue a
replacement student ID card] or [employees: update my existing employee ID card] to provide me with access to
the facility. Access will be automatically terminated at the end of one year if I have not previously notified Carrie
Shaver that I no longer need access. A new user agreement will be required if I need access for more than one year.
I understand and agree that failure to comply with any of the above agreements could be cause for loss of access to
the facilities now and in the future.
I am student staff faculty and plan to use the IUPUC lactation rooms for the purpose of nursing/expressing
breast milk beginning on/about (date)
. I will contact Shannon Love at 812.348.7367 or Carrie
Shaver at 812.348.7345 to develop my customized lactation plan.
Nursing Mother’s Signature:
Date:
Please e-mail initialed and signed form to Shannon Love at [email protected] or Carrie Shaver [email protected].
Office: CC Room 250; fax: 812.348.7243
Lactation consultant: Rene Atkins, RN, IBCLC; Lactation Services Coordinator, 317.528.5620,
[email protected].
Lactation resources:
1. Indiana University Human Resources Policy for Employees: Provisions for Lactating Mothers
2. States Department of Labor: Nursing Mothers
3. Indiana Breastfeeding Coalition: FAQ’s
IUPUC Faculty/Staff member authorization (signature and date)
April 2016
IUPUC Healthy Campus Committee