Report Breastfeeding Discrimination

This form will collect the information we need to determine how best to support a mother who has experienced discrimination due to breastfeeding.

FirstRight uses the information you provide on discrimination reports to compile a database of incidents across the US. The purpose of this database is to gain an understanding of where and how often breastfeeding discrimination occurs. Certain information in our database, such as the month and year of the incident, city and state, and type of facility where the incident took place may be made available to persons who are interested in promoting or reporting on breastfeeding rights. You may indicate that you do not want any of the information relating to your incident to be shared. Unless we have your express permission, we will not share your name, address, phone number, email address, or any of the personal information of your indicated witnesses. If there are other specifics you’d like us to keep confidential, please let us know. We want you to feel safe and comfortable sharing your story with us.

Your Name: *

Your Address:

Your Phone Number: *

Your Email: *

Location of Incident: *

e.g. Anywhere Town Library, Here and Now Hot Dogs, ABZ Preschool

Name of Employee:

Name of person who instigated the incident

Address of location:

Phone Number of Location:

Date of Incident: *

Were there any witnesses?:

yes

Witness Information:

Name, phone number, address, email

Detailed Description of Incident:

Other pertinent information:

e.g. Manager’s name, Employees names, etc.

Legal Disclaimer

(required)
By checking here, I acknowledge I have read the following legal disclaimer.

FirstRight does not provide legal advice nor does it represent that it is or any of its employees or members are legal experts or qualified legal counsel. If you are seeking legal advice, please contact your local bar association, law society, phone book, or online directory to find, or obtain a referral to a competent professional. With respect to the information contained on this site or contained in any communication received from any employee or member of FirstRight, neither FirstRight nor any of its employees or members assumes any legal liability or responsibility for the accuracy, completeness or usefulness of its content.

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Applebee's 2007 Nurse-out