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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: ___________________________________________________________________________
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