Not yet a Member?
HR Magazine is highlighting the next generation of HR leaders.
Is your employee handbook ready for the New Year? With SHRM’s Employee Handbook Builder get peace of mind that your handbook is up-to-date.
Get the HR education you need without travel expenses or time out of the office.
Join us in Chicago for the latest trends and technology in talent management, and what to expect in the future.
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.
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: ___________________________________________________________________________
You have successfully saved this page as a bookmark.
Please confirm that you want to proceed with deleting bookmark.
You have successfully removed bookmark.
Please log in as a SHRM member before saving bookmarks.
Your session has expired. Please log in again before saving bookmarks.
Please purchase a SHRM membership before saving bookmarks.
An error has occurred
Recommended for you
Join SHRM's exclusive peer-to-peer social network
SHRM’s HR Vendor Directory contains over 3,200 companies