TXFWD Application Survey

Texas Family-Friendly Worksite Development Initiative (TXFWD) Cohort 2

Thank you for your interest in participating in the Texas Family-Friendly Worksite Development (TXFWD) Initiative. Consideration for participation in the current opportunity is open to county and municipality governments that are geographically located within a Texas Metropolitan Statistical Area (“MSA entities”) Micro Statistical Areas (µSA entities).

MSA Entities and µSA entities selected for participation in this activity will be expected to commit to completing the following activities during the project period:

Form a multi-disciplinary project planning team, such as described here http://texasmotherfriendly.org/program/form-a-team;
Hold two or more planning team meetings;
Conduct a needs assessment, using some or all of the tools (or similar) described here: http://texasmotherfriendly.org/prgram/assess-your-site
Draft an employee “Mother-Friendly” worksite lactation support policy (http://texasmotherfriendly.org/program/develop-you policy):*
Develop a supplies and materials plan;
Develop a workplan for completion of the policy approval and implementation process; and
Participate in monthly virtual calls with other participating public employers.

*It is anticipated that many participating entities will continue to roll out their employee worksite lactation support programs after the project period is complete. The entity’s employee policy adoption process must, at minimum, be initiated by the end of the project period.

To be considered for participation, please complete all questions for the MSA/µSA entity that will be represented in this project, and submit your responses by June 9, 2017 at 5pm CT. Feel free to email us at motherfriendlyworksite@uth.tmc.edu if you have any questions in the meantime. Your Project Contact Person will be notified by June 19, 2017 at 5pm CT of the application decision.

Question Title

* 1. Provide Legal Business Name and Address Information of Responding Entity

Legal Business Name

Mailing Address 1

Mailing Address 2

Physical Address, if different

City

County

State

Zip

Question Title

* 2. Provide the following information for the project contact person (Project Lead):

First name

Last name

Title/role

Organization name

Mailing Address

Physical Address (if different)

City

State

Zip

County

Phone Number

Email Address

Question Title

* 3. What is the TYPE of entity that would be represented for participation in TXFWD (i.e. represented MSA/µSA entity)? Consideration for participation in the current opportunity is open to county and municipality governments geographically located within a Texas Metropolitan Statistical Area ("MSA entities") + certain Texas Micropolitan Statistical Areas ("µSA entities")?

City

County

Other Political Subdivision (please specify)

Question Title

* 4. What is the NAME of the Represented MSA/µSA entity (i.e. the city name, county name)?

Question Title

* 5. Please name the city or county office or department that will lead this project (Project Lead Department), and describe what resources, expertise, partnerships, etc. are available to the Project Lead Department to support the success of this project.

Question Title

* 6. Per the U.S. Bureau of Labor Statistics, a worksite is an economic unit, generally at a single physical location, where business is conducted or where services or industrial operations are performed. Each location (address) constitutes a unique worksite. There may be more than one business unit, or worksite, at a single address. How many worksites does the Represented MSA/µSA entity currently have?

Question Title

* 7. How many Full Time Equivalent positions are employed by the Represented MSA/µSA entity? (If you are unsure, please estimate)

Question Title

* 8. During the past 12 months, did one or more of the Represented MSA/µSA entity's worksites provide any of the following? (check all that apply)

A written policy on breastfeeding/worksite lactation support for employees?

A private space (other than a restroom) that may be used by an employee to express breast milk?

Access to a breast pump at the worksite

Paid or unpaid break times to allow mothers to pump breast milk

A flex-time policy allowing for employees to flex their schedule to make up any unpaid time (over and above usually provided breaks)

Access to a clean water source and a sink that could be used for washing hands and breast pump equipment

Arrangement for a safe, clean, temperature controlled place where employees can safely store their milk in an employee's own insulated cooler, a breakroom refrigerator, or a dedicated refrigerator?

Infant at work policy/program

Co-located childcare service?

Short-term disability insurance

Other (please specify)

Question Title

* 9. Does this project have leadership "buy-in" within the Represented MSA/µSA entity to support the successful completion of the required milestones during the project period? Please answer "Yes","No", or "Unknown", and briefly describe the status of leadership interest and commitment:

Question Title

* 10. Use this space to tell us anything else you would like for us to know about the Project Lead, Project Lead Department, or Represented MSA/µSA entity that will help us in making selection decisions for this opportunity.