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1. What is your name?
2. What is your current address?
3. Who is your employer?
4. What is the company name you work for?
5. What is the address of your company?
6. What symptoms or conditions have you been experiencing that have impacted your ability to perform your job duties and maintain your overall well-being?
7. When do you want your leave of absence to start?
8. When do you want your leave of absence to end?
9. What is today's date?