I, Name , have received and reviewed the guidelines for the use of the Twin Towers Lactation Room and have had an opportunity to ask questions and have had them answered to my satisfaction. I will begin using the Lactation Room for an approximate period of Number of Months months for the designated purpose of expressing my breast milk, beginning on or about the date of Start Date I understand that Lactation Room access is granted solely for lactation purposes and that I am responsible for the following: bringing my own breast pump and supplies; sanitizing the countertop, sink and other surface areas before and after expressing milk; cleaning up any spills or other untidiness created during use of the room; contacting designated personnel in the event of a spill; securing the room after each use when applicable; respecting the privacy of other lactation room users; and notifying the Georgia Department of Administrative Services (DOAS) when access to the Twin Towers Lactation Room is no longer needed. I understand that I will have access to and may utilize the refrigerator in the Lactation Room for the storage of expressed breast milk. If I elect to use the refrigerator to store expressed breast milk, I understand the following: I am required to label my milk with my name, department, telephone number and the date the milk was expressed. I am required to remove all my stored breast milk by end of business each day. Stored milk that has not been removed by the end of the business day may be disposed of. I am responsible for ensuring that the refrigerator is always kept clean. DOAS and the Georgia Building Authority (GBA) are not responsible for the contents of refrigerator or any loss of or damage to my stored breast milk. I understand that: I should not leave any personal items or equipment in the lactation room. I should not store food or drink in the refrigerator. Ice packs, containers or other accessories are not provided; therefore, it is my responsibility to furnish these items. I understand that failure to comply with any of these provisions could be grounds for denying me further access to the lactation room. Participant Name Date Phone Number Email Employee ID (if applicable) Agency - Select -Abraham Baldwin Agricultural CollegeACCGAdministrative Office of the CourtsAlbany State UniversityAlbany Technical CollegeArmstrong State UniversityAthens Technical CollegeAtlanta Metropolitan CollegeAtlanta Technical CollegeAugusta Technical CollegeAugusta UniversityBainbridge College,Ben Hill County School DistrictBoard of RegentsCentral Georgia Technical CollegeChattahoochee Technical CollegeClark Atlanta UniversityClayton State UniversityCoastal Pines Technical CollegeCollege of Coastal GeorgiaColumbus State UniversityColumbus Technical CollegeCouncil of Superior Court JudgeCriminal Justice Coordinating CouncilCSB-Albany AreaCSB-Avita Community PartnersCSB-ClaytonCSB-Cobb-DouglasCSB-DekalbCSB-Georgia PinesCSB-Highlands RiversCSB-Lookout MountainCSB-McIntosh TrailCSB-Middle FlintCSB-Middle GeorgiaCSB-New HorizonsCSB-OconeeCSB-Pathways CenterCSB-PinelandCSB-River EdgeCSB-Serenity BHSCSB-South GeorgiaCSB-Unison Behavioral HealthCSB-Viewpoint HealthDalton State CollegeDarton CollegeDepartment of AgricultureDepartment of Audits and AccountsDepartment of Banking and FinanceDepartment of Behavioral HealthDepartment of Community AffairsDepartment of Community HealthDepartment of Community SupervisionDepartment of CorrectionsDepartment of DefenseDepartment of Driver ServicesDepartment of Early Care & LearningDepartment of Economic DevelopmentDepartment of EducationDepartment of Human ServicesDepartment of InsuranceDepartment of Juvenile JusticeDepartment of LaborDepartment of LawDepartment of Natural ResourcesDepartment of Public HealthDepartment of Public SafetyDepartment of RevenueDepartment of TransportationDepartment of Veterans ServicesDOASEast Georgia CollegeEmployees Retirement System of GeorgiaFort Valley State UniversityFulton CountyGateway Behavioral Health ServicesGEMAGeorgia Aviation AuthorityGeorgia Building AuthorityGeorgia Bureau of InvestigationGeorgia College & State UniversityGeorgia Commission on Equal OpportunityGeorgia Commission on the HolocaustGeorgia Correctional IndustriesGeorgia Council on Developmental DisabilitiesGeorgia Development AuthorityGeorgia Drugs and Narcotics AgencyGeorgia Environmental Facilities AuthorityGeorgia Environmental Finance AuthorityGeorgia Firefighter Standards and Training CouncilGeorgia Forestry CommissionGeorgia General AssemblyGeorgia Government Transparency and Campaign Finance CommissionGeorgia Gwinnett CollegeGeorgia Highlands CollegeGeorgia Institute of TechnologyGeorgia Lottery CorporationGeorgia National Fairgrounds & AgricenterGeorgia Northwestern Technical CollegeGeorgia Perimeter CollegeGeorgia Piedmont Technical CollegeGeorgia Ports AuthorityGeorgia Professional Standards CommissionGeorgia Public Defenders Standards CouncilGeorgia Public Telecommunications CommissionsGeorgia Real Estate CommissionGeorgia Regents UniversityGeorgia Regional Transportation AuthorityGeorgia Seed Development CommissionGeorgia Southern UniversityGeorgia Southwestern State UniversityGeorgia State Financing & Investment CommissionGeorgia State UniversityGeorgia Student Finance CommissionGeorgia Technology AuthorityGeorgia Trauma Care Network CommissionGeorgia Vocational Rehabilitation AgencyGeorgia World Congress CenterGordon State CollegeGovernor's Office of Highway SafetyGovernor's Office of Student AchievementGovernor's Office of Workforce DevelopmentGwinnett Technical CollegeJekyll Island AuthorityKennesaw State UniversityLake Lanier Islands Development AuthorityLanier Technical CollegeLegacy Behavioral Health ServicesMiddle Georgia State UniversityMiddle Georgia Technical CollegeMoultrie Technical CollegeNorth Georgia Technical CollegeOconee Fall Line Technical CollegeOffice of Planning & BudgetOffice of State Administrative HearingsOffice of the Child AdvocateOffice of the State Inspector GeneralOffice of Treasury & Fiscal ServicesOgeechee Technical CollegeProsecuting Attorneys’ Council 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