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<br /> <br />Form FMLA-2 <br /> <br />CITY OF PARIS <br />FAMILY AND MEDICAL LEAVE <br /> <br />TO BE COMPLETED BY PHYSICIAN <br /> <br />Employee’s Name:______________________________________________________________ <br /> <br /> <br /> <br />Does this employee have a serious health condition? Yes No <br />?? <br />Date of onset of condition_________________________________________________________ <br />Probable duration of incapacity to perform the job_____________________________________ <br />Is hospitalization required? Yes No <br />?? <br />Will he/she be able to perform the essential functions of his/her job? See attached job description. <br /> Yes No <br />?? <br />Is hospitalization required? Yes No <br />?? <br /> <br /> <br /> <br />Return to: City of Paris <br /> <br />Human Resources <br /> P.O. Box 9037 <br /> Paris, Tx 75461-9037 <br /> Fax: 903 785-8519 <br /> <br /> <br />Name of Physician <br />(print):___________________________________________________________ <br /> <br />Signature of <br />Physician:__________________________________________Date________________ <br /> <br />67 <br />