Mother Friendly Employer Application Survey

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1. Please tell us a little about your organization and contact person.

Please tell us a little about your organization and contact person. Name:
Company:
Address:
Address 2:
City/Town:
State:
ZIP/Postal Code:
Email Address:
Phone Number:

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2. Please choose the primary function of your business.

Please choose the primary function of your business. Healthcare

Manufacturing

Education

Government

Service

Retail/Commerce

Other (please specify)

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3. Please describe the size of your organization by choosing the number of total employees.

Please describe the size of your organization by choosing the number of total employees. Less than 25

25-49

50-99

100-499

500 or more

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4. Please choose the following answer that best describes your company.

Please choose the following answer that best describes your company. Private, not-for-profit

Private, for profit

Public

Other (please specify)

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5. Please describe the percentage of women employed by your company.

Please describe the percentage of women employed by your company. Less than 25%

25-49%

50-75%

More than 75%

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6. Please tell us if you drafted a lactation support policy for your worksite.

Please tell us if you drafted a lactation support policy for your worksite. Yes

No

In Progress

Other (please specify)

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7. Please tell us if your policy was adopted by your organization.

Please tell us if your policy was adopted by your organization. Yes

No

In progress

Other (please specify)

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8. Please tell us if a private space (other than a bathroom) was established for lactation.

Please tell us if a private space (other than a bathroom) was established for lactation. Yes

No

In Progress

Other (please specify)

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9. Please choose the following that describe your room.

Please choose the following that describe your room. Multi-purpose room

Lactation room only

Multi-user room

Single-user room

Other (please specify)

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10. Please provide a brief description of the space. The space must be clean, private, have adequate lighting, an electrical outlet, and not be a bathroom. It should have access nearby to a clean safe water source and a sink.

Please provide a brief description of the space. The space must be clean, private, have adequate lighting, an electrical outlet, and not be a bathroom. It should have access nearby to a clean safe water source and a sink.

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11. Did you utilize the resource The Business Case for Breastfeeding?

Did you utilize the resource The Business Case for Breastfeeding? Yes

No

If yes, how?

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12. Please explain how your organization has provided education to all employees regarding the lactation support program, policy, and community resources.

Please explain how your organization has provided education to all employees regarding the lactation support program, policy, and community resources.

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13. Please list how your organization has promoted the lactation support room and policy?

Please list how your organization has promoted the lactation support room and policy?

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14. How do you plan to continue and/or expand your program in the future?

How do you plan to continue and/or expand your program in the future?

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15. As a requirement for Mother Friendly Employer designation, please ENSURE that you have sent a copy of the following to lmmyers@lander.edu. Please check off the things you have already completed.

THANK YOU SO MUCH FOR YOUR PARTICIPATION IN HELPING TO ENSURE WORKING MOTHERS HAVE EMPLOYER SUPPORT!!

As a requirement for Mother Friendly Employer designation, please ENSURE that you have sent a copy of the following to lmmyers@lander.edu. Please check off the things you have already completed. THANK YOU SO MUCH FOR YOUR PARTICIPATION IN HELPING TO ENSURE WORKING MOTHERS HAVE EMPLOYER SUPPORT!! Picture of lactation room

Copy of lactation support policy

List of community lactation resources provided to employees

Mother Friendly Employer Application

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