1.Your Name & Job Title

2.Your Email & Phone Number

3.Company Name & City

4.Company Phone Number

5.Primary Contact (e.g. Supervisor, Manager, Business Owner, etc.)

6.Number of employees at company (*approximately)

7.Tell us about your story!  Describe your “mother-baby friendly” or “family-friendly” program and how the support you have received positively impacted your performance and work environment.

8.Does your program include a lactation room?  If so, describe the space and explain how break times are supported and scheduled.

9.Does your company have written policies that support lactation in the workplace? How are employees educated on these policies?

10.Please tell us more about why you believe your employer should be recognized.