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<br />DRAFT <br /> <br />Form FMLA-3 <br /> <br />CITY OF PARIS <br />FAMILY AND MEDICAL LEAVE <br />F AMIL Y MEMBER <br /> <br />TO BE COMPLETED BY PHYSICIAN <br /> <br />Employee's Name: <br /> <br />Name of Family Member <br /> <br />Does the family member 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 the patient require assistance for basic medical, hygiene, nutritional needs, safety or <br />transportation? 0 Yes 0 No <br />Is the employee's presence necessary to care for the patient? 0 Yes 0 No <br />If yes, for what period of time? <br /> <br />0 Yes <br /> <br />0 No <br /> <br />Return to: <br /> <br />City of Paris <br />Human Resources <br /> <br />P.O. Box 9037 <br /> <br />Paris, Tx 75461-9037 <br /> <br />Fax: 903 785-8519 <br /> <br />Name of Physician (print): <br /> <br />Signature of Physician: <br /> <br />Date <br /> <br />67 <br /> <br />Rev. 10/27/04 <br />