The Consortium for Infant and Child Health (CINCH) is dedicated to protecting the rights of breastfeeding mothers. If you know of an incident related to a woman's right to breastfeed, please report the incident to CINCH. A member of the CINCH Hampton Roads Breastfeeding Education and Advocacy Team (HR-BEAT) will contact you.
 
Responses from this survey will be shared with the Virginia Department of Health.  

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* 1. Name

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* 2. E-mail address

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* 3. Phone number

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* 4. City of residence

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* 5. Date of the incident

Date 

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* 6. Location of the incident

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* 7. Please describe the incident 
Please include the "who" (i.e. manager's name), "where" (i.e. department store on 8th and K), and "what" (i.e. being told to cover up or stop breastfeeding in public) about the incident. 

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* 8. Additional information

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* 9. What is the best way to contact you?

Thank you for completing this incident report form. A member of the CINCH Hampton Roads Breastfeeding Education and Advocacy Team (HR-BEAT) will contact you shortly to follow up.

In the meantime, if you have any questions, please feel free to contact us at CINCH@evms.edu or (757) 446-6039.

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