Lactation Program Assessment Form (Page 2 of 3) in pdf

Lactation Program Assessment Form Page 2

What break policies could be adapted to allow for milk expression breaks?

What new policies would need to be developed to provide for lactation support?

Program Components

What department could

likely serve as the

Wellness division

administrative home for

the lactation

Employee health unit

support program?

Human Resources

Personnel

Other_________________________

What funding is available to

support a

lactation support program?

What realistic options do women currently

Personal oﬃce

have for expressing milk during the work

Oﬃce of another employee

period in privacy (other than a toilet stall)?

Designated lactation room

Other space

If no designated lactation room exists, what

Unused oﬃce space

options might be available for a space with

Closet or other small space

an electrical outlet that can be locked?

A room created within another

space

Other_________________________

What type of breast pump equipment do

None - employees use their own

breastfeeding employees currently receive?

breast pump equipment

Company purchases hospital-

grade electric breast pumps

Company rents hospital-grade

electric breast pumps

Company provides/subsidizes

portable personal use pumps

Lactation Program Assessment Form Page 2