High 5 for Mom & Baby Renewal 2026 High 5 Renewal Application 2026 High 5 Renewal Application 2026 BasicsPractice 1Practice 2Practice 3Practice 4Practice 5Practice 6Practice 7Practice 8Practice 9Practice 10Comments0% Complete1 of 12 Kansas Hospitals and Birth Centers: use this online form to apply for renewal of recognition as a High 5 for Mom & Baby facility. If helpful, you can download an offline sample to gather the information to enter into the official online form below. If your facility is recognized as High 5 Premier (all ten practices), please use the streamlined renewal form available here instead of the below form. If you have questions about High 5 for Mom & Baby or the renewal process, please contact program coordinator Cara Gerhardt coordinator@high5kansas.org. Thank you for your continued commitment to helping ensure successful breastfeeding for Mom & Baby! Note: upon submission of the below form, an email confirmation will be sent to the address entered in the email field below. If you want to save a partial form for later completion, please use the Save Draft function at the bottom of the form. High 5 Renewal Basic Information Date * Facility Name * Facility City * Your Name * Your Name First Name First Name Last Name Last Name Email * Confirm Email * Confirm email Number of deliveries last year * Informational Questions The questions in this first section are intended to inform potential future improvements to High 5, and your responses will not affect renewal eligibility in any way. We appreciate your input. 1. Does your facility currently offer pasteurized donor human milk to patients who require feeding supplementation? Yes No Uncertain 1a. If yes, please attach any policies, handouts, or documentation you use related to providing pasteurized donor human milk. Drop a file here or click to upload Choose File Maximum file size: 67.11MB 1b. If no, what are the barriers to offering pasteurized human donor milk? (Please choose all which apply) Cost Uncertainty about how to obtain donor milk Provider concerns Provider lack of interest Family concerns Family lack of knowledge or interest Storage concerns Workflow issues or concerns Safety of donor milk OtherOther The following Facility Self-Assessment questions relate to the evidence-based High 5 for Mom & Baby practices supporting successful breastfeeding. Application responses should accurately reflect hospital policies and the patient education provided by trained staff. High 5 recognized facilities should answer questions relating to the five or more practices being followed. Note: High 5 for Mom & Baby Premier facilities (implementing all 10 practices) should use the streamlined form at https://healthfund.org/a/high5-premier-renewal-26 instead of this form. The High 5 for Mom & Baby Practices: Facility will have a written maternity care and infant feeding policy addressing the High 5 for Mom & Baby practices supporting breastfeeding Facility will maintain staff competency in lactation support All pregnant women will receive information and instruction on breastfeeding Assure immediate and sustained skin-to-skin contact between mother and baby after birth All families will receive individualized infant feeding counseling Give newborn infants no food or drink other than breastmilk unless medically indicated Practice “rooming in” – allow mothers and infants to remain together 24 hours a day Families will be encouraged to feed their babies when the baby exhibits feeding cues, regardless of feeding methods Give no pacifiers or artificial nipples to breastfeeding infants Provide mothers options for breastfeeding support in the community (such as a telephone number, walk-in clinic information, support groups, etc.) upon discharge If you are human, leave this field blank. Next Page Save Draft