Feedback Form
for breastfeeding in public or
workplace/employment problems

Public Incident (please check only one)

Workplace Incident


Your Name*

Street Address


State Zip Zip

Telephone FaxFax


*Required fields

Date of incident

Describe the incident* Please include the
names of people involved (including supervisors)
what happened
• what you did as follow-up
whether you talked to the supervisor involved



CONFIDENTIALITY STATEMENT: The information you provide on this form is for statistical purposes. Your name will not be released without your permission and you would be contacted via e-mail before any such use.

Please indicate whether you give permission to use your name:

OK to use my name

Please do NOT use my name


What's Out There Already?
There are a number of tools or “supplies” to be familiar with no matter where or what breastfeeding lobbying you are engaged in. The US has numerous documents, not only calling for breastfeeding reform, but also describing what needs to be done. Secure copies of these for background purposes, to quote in letters or testimony, for benchmarking and evaluation, or to simply write your congressman and ask why little or nothing has been done to fulfill the various recommendations. Click on the link below to download a list of advocacy resources and where to get them.

Resources for Breastfeeding Advocacy