Laserfiche WebLink
<br />DRAFT <br /> <br />Form FMLA-2 <br /> <br />CITY OF PARIS <br />F AMIL Y AND MEDICAL LEAVE <br /> <br />TO BE COMPLETED BY PHYSICIAN <br />Employee's Name: <br /> <br />Does this employee have a serious health condition? <br />Date of onset of condition <br />Probable duration of incapacity to perform the job <br />Is hospitalization required? 0 Yes 0 No <br />Will he/she be able to perform the essential functions of his /her job? See attached job description. <br />oYesONo <br /> <br />0 Yes <br /> <br />0 No <br /> <br />Is hospitalization required? <br /> <br />oYesONo <br /> <br />Return to: <br /> <br />City of Paris <br />Human Resources <br /> <br />P.O. Box 9037 <br />Paris, Tx 75461-9037 <br />Fax: 903 785-8519 <br /> <br />Name of Physician (print): <br /> <br />Signature of Physician: <br /> <br />Date <br /> <br />66 <br /> <br />Rev. 10/27/04 <br />