5(a). Model Form of Verdict for Emergency Medical Treatment; No Issue as to the Applicability of F.S. 768.13(2)(b) Verdict We, the jury, return the following verdict: 1. Was there reckless disregard on the part of (defendant hospital, hospital employee, physician) which was a legal cause of [loss] [injury] [or] [damage] to (claimant) (decedent)? Yes No If your answer to question 1 is NO, your verdict is for defendant, and you should not proceed further except to date and sign this verdict form and return it to the courtroom. If your answer to question 1 is YES, please answer question 2. [Refer to Forms 2(a) and (b) for itemized damage interrogatories.] SO SAY WE ALL, this day of __________, 2 _. ____________________________________ FOREPERSON