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1 <br />La <br />CITY OF PARIS <br />FAMILY AND MEDICAL LEAVE <br />FAMILY MEMBER <br />TO BE COMPLETED BY PHYSICIAN <br />Employee's Name: <br />Name of Family Member <br />467- <br />Form FMLA -3 <br />Does the family member 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 the patient require assistance for basic medical, hygiene, nutritional needs, safety or <br />transportation? ❑ Yes ❑ No <br />Is the employee's presence necessary to care for the patient? ❑ Yes ❑ No <br />If yes, for what period of time? <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 />70 Revised 01 -25 -05 <br />