TCHD Breastfeeding Friendly Worksite Award Application Question Title * 1. Name of worksite Question Title * 2. Worksite address Question Title * 3. Worksite website Question Title * 4. Contact person's name Question Title * 5. Contact person's phone number Question Title * 6. Contact person's email address Question Title * 7. Type of worksite For Profit Nonprofit Government agency Other (please specify) Question Title * 8. Worksite size Small (up to 50 employees) Medium (51-499 employees) Large (500+ employees) Question Title * 9. Have you completed all of the award submission requirements? Yes No In Progress Completed and submitted the Worksite's Self-Assessment Form? Completed and submitted the Worksite's Self-Assessment Form? Yes Completed and submitted the Worksite's Self-Assessment Form? No Completed and submitted the Worksite's Self-Assessment Form? In Progress Sent copy of the worksite's breastfeeding support policy to hwilliams@tchd.org? Sent copy of the worksite's breastfeeding support policy to hwilliams@tchd.org? Yes Sent copy of the worksite's breastfeeding support policy to hwilliams@tchd.org? No Sent copy of the worksite's breastfeeding support policy to hwilliams@tchd.org? In Progress Sent picture of the worksite's breastfeeding space to hwilliams@tchd.org? Sent picture of the worksite's breastfeeding space to hwilliams@tchd.org? Yes Sent picture of the worksite's breastfeeding space to hwilliams@tchd.org? No Sent picture of the worksite's breastfeeding space to hwilliams@tchd.org? In Progress Question Title * 10. Is your worksite supporting breastfeeding employees in other ways? Yes No If yes, please share all the ways you are supporting breastfeeding employees. Question Title * 11. Would you like more information about breastfeeding friendly worksites? Yes No thanks Question Title * 12. Would you be interested in receiving training on how to support breastfeeding employees? Yes, I would like to receive in-person training Yes, I would like to receive on-line training options No, I am not interested in training Question Title * 13. Would you like to receive a free copy of the Business Case for Breastfeeding Toolkit? Yes No thanks Question Title * 14. May we recognize your worksite as a Breastfeeding Friendly in Tri-County Health Department press releases, social media and on our website? Yes No Done