CT Breastfeeding Coalition's Breast & Chest Feeding Friendly Worksite Application
Thank you for supporting your employees and helping us to promote, protect and support chest/breastfeeding in Connecticut! Please take a minute to answer the following questions so we may recognize your efforts to create a chest/breastfeeding friendly work environment! If you have any difficulties or questions you can contact us by email:
 info@breastfeedingct.org
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About the Employer/Worksite/Organization
Worksite/Employer Name *
Mailing Address *
Phone Number *
Website
Type of Employer/Worksite/Organization *
Number of Employees *
List all/other locations where your employee lactation support policy is being followed if more than the official address listed above:
Primary Contact Person for the Employee Lactation Support Program/Policy
First & Last Name *
Job Title/Position *
E-Mail *
Phone Number *
Your NAME and EMAIL if different from Primary Contact listed above.
How did you hear about the Breastfeeding Friendly Worksite Recognition? Did a local group, coalition, health department, task force or other agency suggest you apply or support you in the process? Please tell us who referred you: *
Employee Lactation Supports Provided
Employers must provide these three supports at a minimum to qualify for the recognition.
1. Does your business/worksite/organization have an accessible, private space (NOT a bathroom, is shielded from view of public and co-workers, is protected from intrusion) that an employee may use to chest/breastfeed or express/pump their milk? *
2. Does your business/worksite/organization provide employees flexible paid or unpaid break times to express/pump their milk? *
3. A policy describing how your organization ensures all employees are able to access the above supports is required. Please email your employee lactation support policy to info@breastfeedingct.org.

If you do not have a policy or would like any assistance, the CT Breastfeeding Coalition is here to help! Email us info@breastfeedingct.org or visit www.breastfeedingct.org/resources.html 
Other supports. Please check any additional workplace supports provided by your business/worksite/organization.
Check all that apply
I give the Connecticut Breastfeeding Coalition permission to:
Please send us any lactation space or employee support photos that your organization agrees to share on the CBC or It's Worth It websites. You can email them to info@breastfeedingct.org THANK YOU!
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