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, middle) 4a. Position title 4b. Pay plan 4c. Grade/pay level 5. Name of organization (Agency, Department, Office, Division, Branch, etc.) 6. Office telephone number 7. Nature and severity of the medical emergency 8. Individual affected by medical emergency 9. Date medical emergency began (check one) 10. Date medical emergency ended (or is expected to end) Employee Employee's family member 11. Name of physician who will verify the medical emergency. (Attach documentation from the physic.

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