FMLA: Adult Child Disability Medical Inquiry Form

To approve your request for FMLA leave to care for an adult child, [Company Name] is requesting medical information and documentation to determine if the adult child has a disability as defined by the Americans with Disabilities Act (ADA) and amendments. Please have the adult child’s medical care provider complete this form.Return the completed form to [Individual’s Name] with the Certification of Family Member’s Serious Health Condition Form.

Employee Name (print):_______________________________________________________

Name of Adult Child (Patient):_________________________________________________

1.Can you confirm that the daughter’s or son’s serious health condition causes the patient to be “incapable of self care” in at least three “daily living activities” in question 2 listed below?

Yes __ No ___

2.Please check applicable activities:

___ Grooming and hygiene.

___ Bathing and dressing.

___ Feeding and eating.

___ Cooking and preparing meals.

___ Cleaning of dishes and of clothing.

___ Shopping for normal basic living.

___ Taking public transportation.

___ Paying bills, using a bank and post office.

___ Helping to maintain a residence.

___ Other (please specify) ____________________________

3.Does the adult child have a disability as defined by the ADA? Defined as a physical or mental impairment that substantially limits one or more of the major life activities of an individual.

Yes __ No ___

Health Care Provider’s Signature and Date:__________________________________________________________________________

Health Care Provider’s Printed Name:_____________________________________________

Treating Health Care Provider’s Address and Telephone Number: ___________________________________________________________________________

___________________________________________________________________________

Employee Signature and Date: ___________________________________________________________________________

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