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<br /> <br /> Form FMLA-3 <br />CITY OF PARIS <br />FAMILY AND MEDICAL LEAVE <br />FAMILY MEMBER <br /> <br />TO BE COMPLETED BY PHYSICIAN <br /> <br />Employee’s Name:______________________________________________________________ <br />Name of Family Member_________________________________________________________ <br /> <br /> <br /> <br />Does the family member 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 the patient require assistance for basic medical, hygiene, nutritional needs, safety or <br />transportation? Yes No <br />?? <br />Is the employee’s presence necessary to care for the patient? Yes No <br />?? <br />If yes, for what period of time?_____________________________________________________ <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 Physician:__________________________________________Date_________ <br /> <br /> <br />68 <br />