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Pump Kit Giveaway Questionnaire

Thank you for your interest in obtaining a free Medela Symphony pump kit. In order to better serve Penn’s working and studying parents, we ask that you complete the following questionnaire. If you have any questions or concerns about this form, please contact Elisa Foster at elisaf@upenn.edu.

The pump kits are compatible with the Medela Symphony hospital grade breast pumps available in many lactation rooms across campus. They include all the parts you need to use the pumps and two storage bottles.

Looking for more information about lactation and returning to school/work after parental leave? See the map of on-campus lacation spaces and resources for chestfeeding and breastfeeding parents.

First and Last Name

Email Address

Your Age

Your Penn Affiliation

Undergraduate Student (please specify school and graduation year)
Graduate Student (please specify program and year)
Staff (please provide job title)
Full-time Standing Faculty (please specify department)
Part-time/adjunct faculty (please specify department)
Post-Doc (please specify department and year)
Other (please specify your Penn affiliation)

If you are a staff or faculty member, in what building do you primarily work?

Are you an international student or scholar?

Yes
No

Is this pump for use by you or your partner?

Myself
My partner

How many children do you have and/or are expecting? Please specify their ages.

What time(s) of day do you ideally need to pump while on campus? Check all that apply.

Morning (6:00 AM - 12:00 PM)
Afternoon/Evening (12:00 PM - 6:00 PM)
Night (6:00 PM - 12:00 AM)
Late night/Early Morning (12:00 AM - 6:00 AM)

Where on campus do you plan to use the Medela Symphony pump? Check all that apply.

Penn Women's Center
Family Resource Center
Other (Please specify the building)
Undecided

Which lactation spaces, if any, do you currently utilize on campus? Check all that apply.

I use my own office or workspace
On-campus lactation room. Please specify the building(s)
Other - Please specify
I do not currently use a lactation space

How did you learn about the pump kit giveaway program?

How did you learn about lactation spaces at Penn?

When (approximate date) do you plan on picking up your pump? Pickup is available at Penn Women's Center, 3643 Locust Walk. We can arrange contactless pickup upon request.