Breastfeeding-Friendly Worksite Nomination Form

Recognize your business as one of Northern Colorado’s Breastfeeding-Friendly Worksites. Supporting breastfeeding mothers in the work place is not only the law, but is one way for businesses to embrace wellness, impact health care costs, lower absenteeism and be seen as a family-friendly business for potential and current employees. Businesses of all sizes and types are encouraged to apply to share creative solutions to support breastfeeding mothers and employees.

Contact Information

Name of individual completing nomination

First Name

Last Name

Email

Phone

(###)

###

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Business Information

Business Name

Address

Brief description of Business

Award Criteria (Please check all that apply)

Business provides a private room other than a bathroom, in close proximity to their work for expressing milk or nursing

The lactation room has supportive amenities including, but not limited to a comfortable chair, an inside lock on the door, a small table, and an electrical outlet

Business provides all breastfeeding employees flexible breaks to express milk or nurse

Business has a breastfeeding support policy and educates all staff on the policy

May we promote this business as a Breastfeeding Friendly Worksite?

Yes

No

Submit additional documentation to support the nomination, such as testimony from a breastfeeding employee or patron, photo(s) of lactation room(s), workplace policy for supporting breastfeeding, and staff education. You may submit the additional documentation by emailing to:

Mike Schwan, MS.RD.
Weld County Department of Public Health and Environment
1555 N. 17th Avenue
Greeley, CO 80631
970-304-6420 ext. 2343
E-mail: mschwan@weldgov.com