Nebraska DHHS asks for this one-page statement when a parent or caretaker requests child care services because they cannot care for their own children. The physician confirms whether the client meets the DHHS definition of incapacity, then describes its nature, expected duration, specific restrictions, the child care tasks the client cannot do and the weekly hours affected.
The examining physician (the signature line specifies Medical Doctor) completes item 3 onward, including the incapacity finding, and signs with printed name and address. The DHHS service worker fills in the client, worker and local unit details in item 1.
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Incapacity Statement
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The form defines it as any physical or mental illness, impairment or defect so severe that it eliminates the caretaker's ability to provide care for their children. The physician checks either that the client is incapacitated as defined or that the client is not incapacitated.
The nature of the incapacity, its anticipated duration (or an estimated reevaluation date), the specific restrictions that prevent the client from caring for their children, the activities they cannot perform, and how many hours per week they are unable to care for their children.
The signature line reads 'Signature of Examining Physician (Medical Doctor)', followed by the physician's typed or printed name and street address. The DHHS service worker's name, local unit and date appear in item 1. The current edition is CC-3E Rev. 12/19.