VF-3033. Ralph Act (Civ. Code, § 51.7) Instruction No 1 Request by Plaintiff Given as Proposed Refused Withdrawn Request by Defendant Given as Modified Requested by Given on Court's Motion Judge Instruction No 1 We answer the questions submitted to us as follows: 1.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 defendant] [threaten/commit] violent acts against [name of plaintiff] [or [his/her] property]? ____ 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. Was [name of defendant]'s perception of] [name of plaintiff]'s [race/color/religion/ancestry/national origin/political affiliation/sex/sexual orientation/age/disability/citizenship/primary language/immigration status/position in a labor dispute/[insert other actionable characteristic]] a substantial motivating reason for [name of defendant]'s conduct? ____ 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. Would a reasonable person in [name of plaintiff]'s position have believed that [name of defendant] would carry out [his/ her] threats? ____ 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 VF-3033. Ralph Act (Civ. Code, § 51.7) Instruction No 1 Request by Plaintiff Given as Proposed Refused Withdrawn Request by Defendant Given as Modified Requested by Given on Court's Motion Judge Instruction No 1 presiding juror sign and date this form.] [4. Would a reasonable person in [name of plaintiff]'s position have been intimidated by [name of defendant]'s conduct? ____ 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. Was [name of defendant]'s conduct a substantial factor in causing harm to [name of plaintiff]? ____ 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. What are [name of plaintiff]'s damages? [a. Past economic loss [lost earnings [lost profits [medical expenses $ $ $ ] ] ] VF-3033. Ralph Act (Civ. Code, § 51.7) Instruction No 1 Request by Plaintiff Given as Proposed Refused Withdrawn Request by Defendant Given as Modified Requested by Given on Court's Motion Judge Instruction No 1 [other past economic loss Total Past Economic Damages: [b.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 pain/mental suffering:] $ $ $ [d. Future noneconomic loss, including [physical pain/mental suffering:] TOTAL 7. Signed: Presiding Juror What amount do you award as punitive damages? $ VF-3033. Ralph Act (Civ. Code, § 51.7) 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 Dated: 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 2009, December 2010; Renumbered from CACI No. VF-3013 December 2012; Revised June 2013, December 2016