Workplace Street Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Point of Contact Name *

First Name

Last Name

Point of Contact Phone Number *

(###)

###

####

What is the estimated number of employees at the workplace? *

1-10

11-25

26-50

51-100

101-250

251-500

501-1000

1001-5000

5001-10,000

More than 10,000

Does your workplace have a lactation policy? *

Required for recognition

Yes

No

I don't know

We're working on it

Other

If your workplace has multiple locations, does each location implement the lactation policy? *

Required for recognition

Yes

No

Unsure

Do you currently have a lactation space?

Yes, we currently have a space lactating employees can use to express milk or feed their babies

We have a plan for the space if/when the need arises

We have no space or plan for a space yet. We'd like help!

At the worksite(s), the lactation policy is implemented by ensuring the selected components below. *

Answer these questions for your current space, or the space you would use when the need arises. If you are not aware of how policies are implemented at all worksites, please contact the appropriate people to find out. In the interim, please let us know how we can help by contacting us at info@mainebreastfeeds.org

All employees shall be provided flexible and adequate break time to feed their baby or express milk as often as needed while at work (in-person or remotely) for up to 3 years per the Maine State Law.

All lactating employees have access to a private space for expressing milk or nursing.

The space is not a bathroom and is shielded from view and free from intrusion.

The space has an electrical outlet, is close to a sink, and has easy access to hand hygiene.

The space is conveniently located near the employee's workspace.

The space is equipped with window coverings such as a curtain or screens for privacy (if necessary).

The space has comfortable seating and a table or counter space.

The space is clearly marked with a sign indicating its current occupancy to prevent access by other individuals.

We support all breastfeeding, chestfeeding, and human milk feeding families inclusive of their race, ethnicity, immigration status, nationality, creed, age, sexual orientation, gender identity, family structure, primary language, ability, or class.

Our policy is communicated to every incoming and current employee.

We have the Maine DHHS and DOL poster ”Maine Workplaces Support Nursing Moms” displayed

I'm not aware of how all the worksites implement the policy

Do you provide your employees any additional support?

Check all that apply.

Small table near the electrical outlet

Lockable door

Refrigerator for human milk storage

Sink for cleaning pump equipment (other than a shared kitchen or restroom)

Comfortable chair

Computer in the pumping room

Hospital-grade breast pump

Human milk collection bags

List of breast/chestfeeding resources

On-site childcare

Flexible return-to-work policy (part-time, job sharing, telecommuting, flex time, etc.)

Other extra comforts to make the space warm and welcoming (ie. music player, notebook for employees to share notes with one another, etc.)

We do not advertise infant formula or related products directly to consumers.

I give Maine State Breastfeeding Coalition permission to: *

List business name of mainebreastfeeds.org

Link business website on mainebreastfeeds.org

Share photos of our worksite lactation space

None of the above