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MO-07-0035 BFP

Hospital perinatal staff should support the mother’s choice to breastfeed and encourage exclusive breastfeeding for the first 6 months.




4.1 During the hospital stay, an atmosphere that supports exclusive breastfeeding should be encouraged and supported. Interventions may include

  • educating, evaluating and providing appropriate assistance to breastfeeding mothers .
  • avoiding routine feedings of artificial infant milk and other non-mother’s milk fluids to breastfeeding infants (Refer to Policy #8).
  • educating the breastfeeding mother on the rationale for exclusive breastfeeding during the first six months.
  • counseling breastfeeding mothers who choose to supplement, on the importance of exclusive breastfeeding and the risks of early introduction of artificial infant milk.
  • requiring staff to demonstrate competency in lactation support, as defined by the institution.






4.1 Exclusive breastfeeding during the first six months is associated with optimal infant growth and development 3,13,18,19,22,39,43,45 and maternal health. 4,10,17,23,35

4.1.1 Encouraging exclusive breastfeeding during the first few weeks aids in the establishment of an adequate milk supply and appropriate breastfeeding technique.7,11,24,26

4.1.2 Consistent information regarding breastfeeding, increases the likelihood of positive breastfeeding outcomes. 3,28,44

4.1.3 Nurses, doctors, pharmacists and registered dietitians should be knowledgeable of, and demonstrate compliance with, the American Academy of Pediatrics’ policy statement on breastfeeding and the Surgeon General’s goal for the nation.3


See "References" below

Caldwell, K; Turner-Maffei, C: Continuity of Care in Breastfeeding: Best Practices in the Maternity Setting (2009)

Walker, M: Breastfeeding Management for the Clinician (2006)

Breastfeeding Best Practice Guidelines for Nurses (PDF, 5.8MB)Opens a new browser window.from the Registered Nurses’ Association of Ontario

Additional information on exclusive breastfeeding:
http://www.waba.org.my/whatwedo/wbw/wbw04/wbw2004.html (see 2004 Action Folder)
Resources on the Outcomes of Breastfeeding versus Formula Feeding

Patient handouts:

Breastfeeding Task Force of Greater Los Angeles links to free handouts

California Department of Public Health: WIC

Common Sense Breastfeeding by Diane Weissinger

La Leche League International: Womanly Art of Breastfeeding Toolkit:

Massachusetts Breastfeeding Coalition

Websites for Health Care Professionals: http://://www.cdph.ca.gov/HealthInfo/healthyliving/childfamily/Documents/MO-BFP-BBC-WebLinks.doc (Word)Opens a new browser window.

Sources of research based information for health care professionals:

4.2 The mother’s circle of support should be included in the lactation education and decision making process. Staff should assist the family in making an informed infant feeding choice.


4.2 Nurses and doctors promote breastfeeding by identifying and including people who influence the mother’s feeding choice. These may include the father of the baby, other family members, and friends. 8,20





4.3 Nurses, certified nurse midwives and physicians should discuss current recommendations with new mothers regarding the specific medical risks of artificial infant milks to the infant.

Most research has been done regarding the specific risks of cow-based and soy-based milks. It is assumed that other non-human milk sources pose risks for human infants. Species specificity of mammalian milks is well established. There is no evidence to assume that milk of any other species is without risk as a food for human babies.


4.3 Mothers should be well informed in order to make knowledgeable choices about feeding. 7,29

4.3.1 Known risks associated with introduction of cow-based artificial infant milk may

  • increase the risk of diarrhea, upper respiratory infections and otitis media. 3,22
  • provide less than optimal nutritional composition for central nervous system development. 4,42
  • increase the risk of juvenile diabetes 3,22 some allergies 3,24,44, and the risk of Sudden Infant Death Syndrome. 3,22
  • increase the risk of Crohn’s disease, ulcerative colitis and childhood lymphomas 3,22 and alter the flora of the baby’s gut. 22,32
  • decrease infant’s interest in nursing because of longer gut transit time compared to breastmilk. 30,32
  • contribute to childhood obesity. 5,9,15,16,32

4.3.2 Routine use of soy-based artificial infant milk, in lieu of breastfeeding or cow-based artificial infant milk, is not recommended. Multiple concerns regarding soy have led the American Academy of Pediatrics to advise against the routine use of soy-based artificial infant milk. Soy based formulas should only be considered when there is a specific medical indication such as galactosemia or hereditary lactase deficiency. 2

  • Specific risks of soy-based artificial infant milk are listed below.
  • Soy is at least as allergenic as cow milk. 2,25
    Soy is associated with a poorer response to vaccinations compared with breastmilk. 37
    Soy-fed infants have a higher rate of illness than breastmilk fed infants. 43
  • Soy-based artificial infant milk contains much higher levels of isoflavone (estrogen-like compounds) than maternal milk, and results in infant plasma levels of these compounds 200 times those of infants fed maternal milk. The health effects of prolonged exposure to these compounds are unknown.40,41
  • Soy-based artificial infant milk has a relatively high content of aluminum (which competes with calcium for absorption and may contribute to osteopenia), and is not recommended for preterm infants < 1800 g. or infants with intrauterine growth restriction. 2
  • Soy-based artificial infant milk contains much higher levels of manganese than human milk, but multiple infant and artificial milk factors raise questions as to whether infants fed on available soy-based products receive too little or too much manganese and other trace elements. 33

4.3.3 Goat milk is not recommended as infant food.

  • Initial studies show goat milk to be at least as problematic as modified cow milk substitutes.
  • The basic composition of goat milk is unlike that of human milk and would require modification to have protein content similar to that of human milk.
  • Clinical and laboratory studies have shown allergic reactions to goat milk in nearly 100% of children allergic to cow milk. 6,39


Free Downloads:

4.4 Nurses, certified nurse midwives and physicians should share current recommendations with new mothers regarding the specific nutritional and medical risks of early introduction of water or glucose water. Patient education should also include cautioning against the use of infant teas and electrolyte replacement fluids (Refer to Policy # 8 for a discussion of supplementation).


4.4 Rationale for avoiding introducing water or glucose water to the infant follows.

4.4.1 Higher protein levels in colostrum have a more stabilizing effect on blood glucose levels than glucose water. 30,32,34

4.4.2 Glucose water with 6 kcal/oz can give the infant a sense of fullness without providing adequate nutrition (colostrum and breastmilk provide 17-20 kcal/oz). 24

4.4.3 Water supplements have not been shown to prevent or ameliorate hyper-bilirubinemia in the neonatal period. 1,30,32


Martin-n-Calama J, Bunuel J, Valero MT, Labay M, Lasarte JJ, Valle F, de Miguel C. The effect of feeding glucose water to breastfeeding newborns on weight, body temperature, blood glucose, and breastfeeding duration. J Hum Lact 1997 Sep;13(3):209-13 [Abstract]







Exclusive Breastfeeding: The only water source young infants need (PDF)Opens a new browser window.

American Academy of Pediatrics’ Clinical Guidelines: Management of Hyperbilirubinemia in the Newborn Infant of 35 or More Weeks Gestation
Tool to the above recommendations: www.bilitool.org
Patient information on Jaundice: Dr. Jack Newman – Breastfeeding and Jaundice


4.5 Nurses, certified nurse midwives, physicians and registered dietitians should educate breastfeeding mothers regarding the risks of introducing artificial infant milk and artificial nipples in order to optimize exclusive breastfeeding. Bottles should not routinely be placed in babies’ cribs, care supplies, and/or mothers’ rooms.


4.5 Mothers are likely to follow recommendations given by perinatal professionals. Supplementation during this time will decrease the likelihood that extended breastfeeding will occur. 12,24,26,36,44

(Refer to Policy #7 for a discussion of the relationship between pacifiers, breast stimulation & milk production).


Academy of Breastfeeding Medicine (www.bfmed.org) Supplementation Protocol: ABM Clinical Protocol #3: Hospital Guidelines for the Use of Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2009 (PDF)Opens a new browser window.

4.6 Information regarding the cost of purchasing artificial infant milk should be provided.


4.6 Artificial milks are expensive and less convenient than breastmilk. 3

4.6.1 Formula needs to be prepared carefully and with consistent accuracy to provide adequate nutrition to the infant. Pre-mixed formulas available in the hospital are often not available to the new mother after discharge. Therefore, non-breastfeeding mothers should be instructed and observed to assure competency with formula preparation.


Parent handout;
 What if I want to wean my baby? By Diane Weissinger

Mothers who choose to bottlefeed: be aware of the following (Dr. Michal Young)

A referenced handout with high reading level is available through Infact Canada:Fourteen Risks of Formula Feeding (PDF)Opens a new browser window.



4.7 The mother’s health status should be considered in relation to HIV serology, chemical dependency, chemotherapy treatments and other medical conditions or therapies where breastfeeding may be contraindicated.


4.7 Certain maternal conditions may preclude breastfeeding.

4.7.1 Breastfeeding is contraindicated for HIV positive mothers in the United States. The risks of vertical transmission of infection to the infant via mother’s milk, and/or exposure to life-long medication, appear to exceed the risks of artificial infant milk feeding. 31,32

4.7.2 Breastfeeding is contraindicated for mothers receiving chemotherapy. 31,32

4.7.3 Breastfeeding is contraindicated for women who are positive for Human T Cell Leukemia Virus (HTLV-1 and HTLV-2). 31


CDC – Contraindications to breastfeeding


4.8 Medical conditions that may require extra counseling and supervision or a change from a less desirable to a more desirable medication in a given class, should be addressed.


4.8 Breastfeeding may be supported in other maternal conditions.

4.8.1 Maternal Hepatitis A infection does not put the infant at risk for clinical disease, though the infant and mother should receive gammaglobulin.4,31

4.8.2 Breastfeeding is not contraindicated in infants of mothers who have active Hepatitis B, though these infants must be given Hepatitis B immune globulin and Hepatitis B vaccine as soon as possible postpartum.4,31

4.8.3 Mothers infected with hepatitis C virus (HCV) “should be counseled that transmission of HCV by breastfeeding is theoretically possible, but has not been documented. According to current guidelines of the US Public Health Service, maternal HCV infection is not a contraindication to breastfeeding. The decision to breastfeed should be based on informed discussion between a mother and her health care professional.” 3,38

4.8.4.For other medical conditions or therapies, refer to a reliable reference to weigh the risks and benefits of breastfeeding. 21,27,29,31


Conditions that are NOT contraindications to breastfeeding:

Drugs and Lactation Database (LactMed)


4.9 Nurses, certified nurse midwives, physicians and registered dietitians should discuss exclusive breastfeeding with mothers and provide written material and specific resources for follow-up. The information should include normal breastfeeding patterns and normal output of urine and stool. Mothers should receive a tool to assess adequate feeding/output, e.g. feeding log.


4.9 Mothers who are encouraged to exclusively breastfeed need support and available resources in the event that early breastfeeding complications occur. 20,29

The newborn can suffer from dehydration, hyperbilirubinemia and electrolyte imbalances if exclusive breastfeeding does not progress normally. 1,3,4,11,14


See Reference #11 below


4.10 “All breastfeeding newborn infants should be seen by a pediatrician or other knowledgeable and experienced health care professional at 3-5 days of age as recommended by the AAP.”42


4.10 “Weight loss in an infant of greater than 7% from birth weight indicates possible breastfeeding problems and requires more intensive evaluation of breastfeeding and possible intervention to correct problems and improve milk production and transfer.”3


( See also reference 11 below)


Policy #4 References:

1. American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia. (2004). Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics, 114(1), 297-316. [Abstract]
2. American Academy of Pediatrics Committee on Nutrition. (1998). Soy protein-based formulas: Recommendations for use in infant feeding. Pediatrics. 101(1), 148-153. (Abstract)
3. American Academy of Pediatrics Policy Statement (2005). Breastfeeding and the use of Human Milk, Pediatrics, 115, 496-506. (2005 Version)
4. American College of Obstetrics and Gynecology. (July 2000). Breastfeeding: Maternal and infant aspects. (Educational Bulletin No. 258). Washington, DC: Author.
5. Arenz, S., Ruckerl, R., Koletzko, B., & von Kries, R. (2004). Breast-feeding and childhood obesity—a systematic review. International Journal of Obesity Related Metabolic Disorders, 28(10), 1247-1256. (Abstract)
6. Bellioni-Businco, B., Paganelli, R. Lucenti, P., Giampietro, PG., Perborn, H., & Buscinco, L. (1999). Allergenicity of goat’s milk in children with cow’s milk allergy. Journal of Allergy and Clinical Immunology. 103(6): 1191-1194.
7. Chezem, J., Friesen, C., & Boettcher, J. (2003). Breastfeeding knowledge, breastfeeding confidence, and infant feeding plans: Effects on actual feeding practices. Journal of Obstetric, Gynecologic and Neonatal Nursing, 32(1), 40-47. (Abstract)
8. Colin, W. B., & Scott, J. A. (2002). Breastfeeding: Reasons for starting, reasons for stopping and problems along the way. Breastfeeding Review, 10(2), 13-19. (Abstract)
9. Dewey, K.G. (2003). Is breastfeeding protective against child obesity? Journal of Human Lactation, 19, 9-18. (Abstract)
10. Dewey, K. G. (2004). Impact of breastfeeding on maternal nutritional status. (Abstract) In L.K. Pickering, A.L. Morrow, R.J. Schanler, and G.M. Ruiz-Palacios (Eds.) Protecting Infants Through Human milk: Advancing the Scientific Evidence Base (pp. 91-100). New York: Plenum Publishers.
11. Dewey, K. G., Nommsen-Rivers, L. A., Heinig, M. J., Cohen, R. J. (2003). Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss. Pediatrics, 112(3), 607-619.
12. DiGirolamo, A. M., Grummer-Strawn, L. M., & Fein, S. (2001). Maternity care practices: Implications for breastfeeding. Birth, 28(2), 1523-1536. (Abstract)
13. Duncan, B., Ey, J., Holberg, C. J., Wright, A. L., Martinez, F. D., Taussig, L. M. (1993). Exclusive breastfeeding for at least 4 months protects against otitis media. Pediatrics, 91(5), 867-872 (Abstract).
14. Gartner, L. (1994). On the question of the relationship between breastfeeding and jaundice in the first 5 days of life. Seminars in Perinatology, 18(6), 502-509.
15. Gillman, M. W., Rifas-Shiman, S. L, Camargo, C. A., Berkey, C. S., Frazier, A.L., Rockett, H. R., et al. (2001). Risk of overweight among adolescents who were breastfed as infants. Journal of the American Medical Association. 258(19), 2461-2467. (Abstract)
16. Grummer-Strawn, L. M., Mei, Z., & Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System. (2004). Does breastfeeding protect against pediatric overweight? Analysis of longitudinal data from the Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System. Pediatrics, 113(2), 81-86.
17. Gwinn, M., Lee, N. C., Rhodes, P. H., Layde, P. M., Rubin, G. L. (1990). Pregnancy, breast feeding, and oral contraceptives and the risk of epithelial ovarian cancer. Journal of Clinical Epidemiology, 43(6), 559-568.
18. Kramer, M. S., Guo, T., Platt, R. W., Sevkovskaya, Z. Dzikovich, I., Collet, J. P. et al. (2003). Infant growth and health outcomes associated with 3 compared with 6 mo of exclusive breastfeeding. American Journal of Clinical Nutrition, 78(2), 291-295. (Abstract)
19. Kramer, M. S., & Kakuma, R. (2004). The optimal duration of exclusive breastfeeding: A systematic review. Advances in Experimental Medicine and Biology, 554, 63-77. (Abstract)
20. Kuan, L. W., Britto, M., Decolongon, J., Schoettker, P. J., Atherton, H. D., & Kotagal, U.R. (1999). Health system factors contributing to breastfeeding success. Pediatrics, 104, 28-34.
21. Hale, T. (2004). Medications & mothers' milk: a manual of lactational pharmacology (11th ed.). Amarillo, TX: Pharmasoft Medical Publishing.(ordering information)
22. Heinig, J. & Dewey, K. (1996). Health advantages of breastfeeding for infants: A critical review. Nutrition Research Reviews, 9, 89-110.
23. Heinig, J. & Dewey, K. (1997). Health effects of breastfeeding for mothers: A critical review. Nutrition Research Reviews, 10, 35-56.
24. Henrikson, M. (1990). A policy for supplementary/complementary feedings for breastfed newborn infants. Journal of Human Lactation, 6(1), 11-14. (Abstract)
25. Hill, D. J., Hosking, C. S., & Heine, R. G. (1999). Clinical spectrum of food allergy in children in Australia and South East Asia: Identification and targets for treatments. Annals of Internal Medicine, 31 (4): 272-281.
26. Hill, P. D. & Humenick, S. S. (1997). Does early supplementation affect long-term breastfeeding? Clinical Pediatrics, 36(6), 345-351. [Abstract]
27. Huggins, K. (1999). The nursing mother’s companion (4th ed.). (pp. 14-16). Boston: Harvard Common Press.
28. International Lactation Consultant Association. (June, 2005). Clinical guidelines for the Establishment of Exclusive Breastfeeding. Author.
29. International Lactation Consultant Association. Summary of Hazards of Infant Formula, Part 1, 2 and 3. Author. Available at http://ICLA.ORG/
30. Lawrence, R. A. (1987). The management of lactation as a physiologic process. Clinics in Perinatology, 14(1), 1-10.
31. Lawrence, R. A. (1997). A review of the medical benefits and contraindications to breastfeeding in the United States. Maternal and Child Health Technical Information Bulletin. Arlington, VA: National Center for Education in Maternal and Child Health. (PDF)Opens a new browser window.
32. Lawrence, R. A., & Lawrence, R. M. (2005). Breastfeeding: A guide for the medical professional (6th ed.). St. Louis, MO: Mosby (pp. 453-455, 115 & 1060, 304 & 536-537, 246-247, 587-588).
33. Lonnerdal, B. (1994, September). Nutritional aspects of soy formula. Acta Paediatrica Supplement, 402, 105-108.
34. Martin-Calama, J., Bunuel, J., Valero, M. T., Labay, M., Lasarte, J. J., Valle, F., et al. (1997). The effect of feeding glucose water to breastfeeding newborns on weight, body temperature, blood glucose, and breastfeeding duration. Journal of Human Lactation, 13, 209-213. [Abstract]
35. Newcomb, P. Storer, B. E., Longnecker, M. P., Mittendorf, R., Greenberg, E. R., Clapp, R. W. et al. (1994). Lactation and a reduced risk of premenopausal breast cancer. The New England Journal of Medicine, 330(2), 81-87.
36. Newman, J. (1990). Breastfeeding problems associated with the early introduction of bottles and pacifiers. Journal of Human Lactation, 6(2), 59-63. [Abstract]
37. Ostrom, K. M, Cordle, C. T., Schaller, J. P., Winship, T. R., Thomas, D. J., Jzcobs, J. R., Blatter, M. M., Cho, S. Gooch, W. M. III, Granoff, D. M., Faden, H., Pickering, L.K. (2002). Immune status of infants fed soy-based formulas with or without added nucleotides for 1 year: Part 1: Vaccine responses and morbidity. Journal of Pediatric Gastroenterology and Nutrition, 34(2), 137-144. (Abstract)
38. Pikering, L. (Ed.). (2003). Red Book: 2003 Report of the Committee on Infectious Diseases (26th ed.). Elk Grove Village, IL: American Academy of Pediatrics.(http://www.aap.org/)
39. Restani, P.,Gaiaschi, A., Plebani, A., Beretta, B., Cavagni, G., Fiocchi, A., et al. (1999). Cross-reactivity between milk proteins from different animal species. Clinical and Experimental Allergy, 29(7), 997-1004. [Abstract]
40. Setchell, K., Zimmer-Nechemias, L., Cai, J., & Heubi, J. (1998). Isoflavone content of infant formulas and the metabolic fate of these phytoestrogens in early life. American Journal of Clinical Nutrition, 68(suppl), 1453S-1461S. [Full Text - Abstract (PDF)Opens a new browser window.
41. Sheehan, D. M. (1998) Herbal medicines, phytoestrogens and toxicity: Risk benefit considerations. Proceeding of the Society for Experimental Biology & Medicine, 217(3), 379-85.
42. Slusser, W. & Powers, N. (1997). Breastfeeding update I: Immunology, nutrition and advocacy. Pediatrics in Review, 18(4), 111-119.
43. Walker, M. (1993). A fresh look at the risks of artificial infant feeding. Journal of Human Lactation, 9(2), 97-107.
44. Winnikoff, B., Laukaran, V. H., Myers, D., & Stone, R. (1986). Dynamics of infant feeding: Mothers, professionals, and the institutional context in a large urban hospital. Pediatrics, 77(3), 357-365.
45. World Health Organization. (2002). The Optimal Duration of Exclusive Breastfeeding. Report of an Expert Consultation. Geneva, Switzerland: Author. Available at http://www.who.int/chil-adolescent-health/publications/NUTRITION/WHO_FCH_CAH_01.24.htm

Additional References:

Agency for Healthcare Research and Quality (AHRQ): Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries, April, 2007 Report

American Academy of Pediatrics & the American College of Obstetricians and Gynecologists:: Breastfeeding Handbook for Physicians”; 2006, American Academy of Pediatrics, Elk Grove Village, IL;

Bartick M,  Reinhold A, “The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis” PEDIATRICS (doi:10.1542/peds.2009-1616) [Abstract]

Caldwell, K; Turner-Maffei, C: Continuity of Care in Breastfeeding: Best Practices in the Maternity Setting (2009)

Caglar, M. K., Ozer, I., & Altugan, F. S. (2006). “Risk factors for excess weight loss and hypernatremia in exclusively breast-fed infants”. Braz J Med Biol Res, 39(4), 539-544.

Ip S, et al (2007). “Breastfeeding and maternal and infant health outcomes in developed countries”. Evid Rep Technol Assess (Full Rep).  Apr;(153):1-186. [Abstract]

Kramer MS et al: Breastfeeding and Child Cognitive Development: New Evidence From a Large Randomized Trial Arch Gen Psychiatry. 2008;65(5):578-584. [Abstract]

Ladomenou F, Moschandreas J, Kafatos A, Tselentis Y, Galanakis E. ”Protective effect of exclusive breastfeeding against infections during infancy: a prospective study”. Arch. Dis doi:10.1136/adc.2009.169912 [Abstract]

McNiel ME, Labbok MH, Abrahams SW. “What are the risks associated with formula feeding? A re-analysis and review”. Breastfeed Rev. 2010 Jul;18(2):25-32.

Martin-n-Calama J, Bunuel J, Valero MT, Labay M, Lasarte JJ, Valle F, de Miguel C. The effect of feeding glucose water to breastfeeding newborns on weight, body temperature, blood glucose, and breastfeeding duration. J Hum Lact 1997 Sep;13(3):209-13 [Abstract]

Moschonis G, Grammatikaki E, Manios Y. Perinatal Predictors of Overweight at Infancy and Preschool Childhood: the GENESIS Study. International Journal of Obesity, 2008.
     The objective of the study was to identify perinatal parameters and characteristics predisposing children to an increased risk of overweight during infancy and preschool years.  N=2,374 preschoolers 1-5 years old.
     Results show that children that were exclusively breastfed were .49 and .54 times less likely for being overweight at 6 and 12 months respectively than those that were exclusively formula fed. When developing a public health strategy to reduce prevalence of childhood overweight and related chronic diseases later in life, breastfeeding is among the parameters that should be priorities.

Stuebe A. “The Risks of Not Breastfeeding for Mothers and Infants” Rev Obstet Gynecol. 2009 Fall; 2(4): 222–231. [Abstract]

Sullivan S, Schanler RJ, Kim JH, Patel AL, Trawöger R, Kiechl-Kohlendorfer U, Chan GM, Blanco CL, Abrams S, Cotten CM, Laroia N, Ehrenkranz RA, Dudell G, Cristofalo EA, Meier P, Lee ML, Rechtman DJ, Lucas A.   “An exclusively human milk-based diet is associated with a lower rate of necrotizing enterocolitis than a diet of human milk and bovine milk-based products”. J Pediatr. 2010 Apr;156(4):562-7.e1. Epub 2009 Dec 29. [Abstract]

Walker, M: Breastfeeding Management for the Clinician 2nd Edition (2011)

Hospital Self-Appraisal Questionnaire (Word)Opens a new browser window.

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Last modified on: 3/8/2011 11:28 AM