Business/Organization Name (required)

Business/Organization Address 1

Business/Organization Address 2

City (required)

State (required)

Zip (required)

Businesses/Organizations Type (required)

Contact Name (required)

Email (required)

Phone Number


Number of FTE (Full-Time Equivalent)

Following submission of the Family Friendly Workplace Application, a FFW Engagement Specialist will contact and meet with the FFW applicant to verify application responses. Please have written documents ready and available to support application responses. (Examples: written personnel policies, written employer practices, etc.)

Question 1

1. Healthcare Coverage. Please note, points are only awarded for premiums that include family coverage. Select one:

Select one of the four categories listed above.

To calculate the percentage of premium paid by the employer one must: Divide the employer paid monthly premium by the total monthly premium to get X number. Then proceed to multiply that number by 100 to get the exact percentage premium paid by the employer.

Question 2

2. Healthcare Coverage.
What type of healthcare benefits does employer provide? Select all that apply:

Select any of the above listed coverage benefits an employer provides. An employer will gain additional points for contributing to an HRA/HSA/FSA Account.

Question 3

3. Childcare Cost Support. Does the employer provide financial support for childcare? Select all that apply:

If an employer pays a percentage of family expenses for childcare at a 3-star rating or higher by the Young Star’s childcare rating system standard, please select one level that applies. The maximum number of categories that may be selected is four (Employer offers on-site child care at a 3-star rating or higher, employer pays a percentage of family expenses for childcare at a 3-star rating or higher, employer contributes to a FSA, and employer offers a FSA).

Wisconsin YoungStar Website:

Employee Schedule Flexibility for Family
Paid Time Off (PTO).

Includes employee vacation, sickness, doctor visits; children and family sickness, appointments, activities, care; attend parent and/or child classes; other family commitments

Question 4(a)

4(a). Paid Time Off (PTO) for full-time employees. Select One:

Question 4(b)

4(b). Paid Time Off (PTO) for Part-time employees. Select One:

Question 5

5. Additional Paid Time Off for Maternity, Paternity, and Bereavement Leave. Select up to three:

Question 6

6. Unpaid Time Off. Select all that apply:

Select all that apply. Please note, employers who have 50 or more employees (for at least 20 work weeks in the current or preceding calendar year) are obligated by the Family and Medical Leave Act to provide employees with up to 12 workweeks of unpaid leave (this time may be paid at the employer’s discretion). An employer with 50 or more employees will only gain unpaid maternity and/or paternity leave points if it provides unpaid leave beyond the 12 weeks of paid or unpaid time. If an employer has less than 50 employees, such company is not obligated to provide any unpaid leave, but will acquire points if it does provide unpaid maternity and/or paternity leave.

Please note that the words “maternity” and “paternity” must appear in the written company policy to receive points.

Question 7

7. Flexible Employee Work Time. Does employer provide any of these work options? Select all that apply:

To receive points for variable day or variable workweek, it must be an exception to the normal rule and due to family obligations. Examples of variable day or variable workweek include: 1) school time hours to allow parents to drop off and pick up children, 2) flex-time to accommodate childcare/eldercare schedules. Evidence may be found in personnel files with the employer-employee agreement documented for a specified time.

Question 8

8. Amenities/Services. Does employer provide any of these amenities or services? Select all that apply:

Select all that apply. To receive points:
- For preferred parking, there must be outside signage designating parking for pregnant moms with a photograph for documentation.
- For nursing or expressing moms, there must be a private area (not bathroom, lunchroom) with a designated refrigerator (not the employee lunchroom refrigerator).
- For family friendly public areas, there must be a specified child play area with table, chairs, books, and/or toys.

Question 9

9. Early Childhood Education Initiatives. Does employer provide any of the following? Select all that apply:

To receive points for early childhood literature for employees, employers must actively bring early childhood information to attention of their employees through articles, books, videos, and other resources. Examples include discussing and distributing information at company meetings, putting buck slip in paychecks, including articles in company newsletter, etc. These may be obtained from a local family resource center or other family-oriented agencies or organizations.

Question 10

10. Financial Support for Success by 6. Select all that apply: