Author: Ramirez, Carolina

Employee Lactation Space Assessment

Assessment Date:			Assessor:
Worksite:			Contact Name:

MDH Minimum Criteria for Employee Lactation Spaces:
Be in an accessible location, within 5 minutes or less of breastfeeding employees' workstations - multiple sites should be provided if it will take employees more than 5 minutes to walk from their work stations to the lactation space / Be a private space, other than a bathroom, that is shielded from view and free from intrusion by coworkers and the public. A locking door is ideal. If a locking door cannot be provided, the employer must be able to explain how they ensure privacy (State & Federal law) / Include access to an electrical outlet (State law) / Include a comfortable chair / Include a small table or surface to support pumping equipment / Have or be located near clean refrigerator space for milk storage / Have or be located near a place to wash hands and clean pump equipment

Criteria		Y/N
Accessible Location
Private
Electrical Outlet Access
Comfortable Chair
Table/Surface
Fridge Access Nearby
Running Water Nearby

Pump:
How many staff have access to the room if needed?
Are there staff who would not be able to access the room easily due to job circumstances (e.g. home visits, inspections)?
Scheduling/ reserving the room on a daily basis?
Process for accessing the room?
How often is the room cleaned? Who is responsible?
Does the room have a space for allowing users to share positive breastfeeding messages, pictures of babies?
Dimmable lights, lamp, or overhead lights?
Does the room have breastfeeding resources?

Insert your company logo here

Employee Lactation Space Assessment

Assessment Date:			Assessor:
Worksite:			Contact Name:

Rating Scale					TOTAL
	0	1	2	3	Rating
Privacy	No private space; or only a bathroom space available	Private space, shielded from view	+ a sign indicating the space is in use	+ room locks from the inside
Electrical Outlet	Not available	Outlet in room, difficult to access	Outlet near chair; not blocked by furniture	Multiple outlets
Chair	No chair available or chair not comfortable	Chair is comfortable, but needs replacing	Chair is comfortable; no need to replace, is wipeable	Chair is comfortable; no need to replace, is wipeable, upright position
Table	No surface or surface is too small to support pumping equipment	Surface accommodates pumping equipment	Surface accommodates pumping equipment and some personal items	Surface accommodates pumping equipment, personal items, and items for work
Refrigerator	Not available	Milk is stored in a public area refrigerator or personal cooler	Employer provides persona coolers for storing milk	Mini-fridge exclusively for breastmilk; inside or outside room
Sink	Not available	Bathroom sink is within 2 minute walk	Kitchen sink is within 2 minute walk	Room has functional sink
Disinfectant Wipes	Not available	Available, but expired or dried	Available	Available and extra stock inside room
Multi-user Breastpump	Not available	Available; employee pays cost for attachment kits	Available; employer subsidizes cost for attachment kits	Available; employer provides attachment kits
Cleanliness	Not clean; overflowing trash, dirty floors and/or surfaces	Emptied trash, but surfaces are dirty	Emptied trash and surfaces are clean	Emptied trash, room gives impression of being recently cleaned
Functional Room	No workspace provided	Pumping equipment surface allows for some work items	Desk or additional surface provided	Desk or additional surface provided, Wi-Fi, computer and/or docking station
TOTAL