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t X <br />Form FMLA -2 <br />CITY OF PARIS <br />FAMILY AND MEDICAL LEAVE <br />TO BE COMPLETED.BY PHYSICIAN <br />Employee's Name: <br />Does this employee have a serious health condition? ❑ Yes ❑ No <br />Date of onset of condition <br />Probable duration of incapacity to perform the job <br />Is hospitalization required? ❑ Yes ❑ No <br />Will he /she be_ able to perform the essential functions of his/her job? See attached job description. <br />❑ Yes ❑ No — <br />Is hospitalization required? ❑ Yes ❑ No <br />Return to: City of Paris <br />Human Resources <br />P.O. Box 9037 <br />Paris, Tx 75461 -9037 <br />Fax: 903 785 -8519 <br />Name of Physician (print): <br />Signature ofPhysician: Date <br />69 Revised 01 -25 -05 <br />