VF-3001. Public Entity Liability (42 U.S.C. § 1983) Instruction No 1 Request by Plaintiff Given as Proposed Refused Withdrawn Request by Defendant Given as Modified Requested by Given on Court's Motion Judge Instruction No 1 We answer the questions submitted to us as follows: 1. Did [name of local governmental entity] have an official [policy/custom] [specify policy/custom]? ____ Yes ____ No If your answer to question 1 is yes, then answer question 2. If you answered no, stop here, answer no further questions, and have the presiding juror sign and date this form. 2. Did [name of local governmental entity] know, or should it have been obvious to it, that this official [policy/custom] was likely to result in a deprivation of the right [specify right violated]? ____ Yes ____ No If your answer to question 2 is yes, then answer question 3. If you answered no, stop here, answer no further questions, and have the presiding juror sign and date this form. 3. Was [name of officer or employee] an [officer/employee/[other]] of [name of local governmental entity]? ____ Yes ____ No If your answer to question 3 is yes, then answer question 4. If you answered no, stop here, answer no further questions, and have the presiding juror sign and date this form. VF-3001. Public Entity Liability (42 U.S.C. § 1983) Instruction No 1 Request by Plaintiff Given as Proposed Refused Withdrawn Request by Defendant Given as Modified Requested by Given on Court's Motion Judge Instruction No 1 ____ Yes ____ No If your answer to question 3 is yes, then answer question 4. If you answered no, stop here, answer no further questions, and have the presiding juror sign and date this form. 4. Did [name of officer or employee] [intentionally/[insert other applicable state of mind]] [insert conduct allegedly violating plaintiff's civil rights]? ____ Yes ____ No If your answer to question 4 is yes, then answer question 5. If you answered no, stop here, answer no further questions, and have the presiding juror sign and date this form. 5. Did [name of officer or employee]'s conduct violate [name of plaintiff]'s right [specify right]? ____ Yes ____ No If your answer to question 5 is yes, then answer question 6. If you answered no, stop here, answer no further questions, and have the presiding juror sign and date this form. 6. Did [name of officer or employee] act because of this official [policy/custom]? ____ Yes ____ No If your answer to question 6 is yes, then answer question 7. If you VF-3001. Public Entity Liability (42 U.S.C. § 1983) Instruction No 1 Request by Plaintiff Given as Proposed Refused Withdrawn Request by Defendant Given as Modified Requested by Given on Court's Motion Judge Instruction No 1 answered no, stop here, answer no further questions, and have the presiding juror sign and date this form. 7. What are [name of plaintiff]'s damages? [a. Past economic loss [lost earnings [lost profits [medical expenses [other past economic loss Total Past Economic Damages: [b. Future economic loss [lost earnings [lost profits [medical expenses [other future economic loss $ $ $ $ ] ] ] ] ] $ $ $ $ $ ] ] ] ] ] Total Future Economic Damages: $ [c. Past noneconomic loss, including [physical VF-3001. Public Entity Liability (42 U.S.C. § 1983) Instruction No 1 Request by Plaintiff Given as Proposed Refused Withdrawn Request by Defendant Given as Modified Requested by Given on Court's Motion Judge Instruction No 1 pain/mental suffering:] [d. Future noneconomic loss, including [physical pain/mental suffering:] TOTAL Signed: Dated: $ $ $ ] ] Presiding Juror After [this verdict form has/all verdict forms have] been signed, notify the [clerk/bailiff/court attendant] that you are ready to present your verdict in the courtroom. _____________________________________________________________________________ New September 2003; Revised April 2007, December 2010, June 2011; Renumbered from CACI No. VF-3005 December 2012; Revised December 2016