VF-2504. Retaliation (Gov. Code, § 12940(h)) Instruction No 1 Request by Plaintiff Given as Proposed Refused Withdrawn Request by Defendant Given as Modified Requested by Given on Court's Motion Judge Instruction No 1 We answer the questions submitted to us as follows: 1.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 plaintiff] [describe protected activity]? ____ 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 defendant] [discharge/demote/[specify other adverse employment action]] [name of plaintiff]?] [or] [Did [name of defendant] engage in conduct that, taken as a whole, materially and adversely affected the terms and conditions of [name of plaintiff]'s employment?] ____ 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 plaintiff]'s [describe protected activity] a substantial motivating reason for [name of defendant]'s [decision to [discharge/demote/[specify other adverse employment action]] [name of plaintiff]/conduct]? VF-2504. Retaliation (Gov. Code, § 12940(h)) Instruction No 1 Request by Plaintiff Given as Proposed Refused Withdrawn Request by Defendant Given as Modified Requested by Given on Court's Motion Judge Instruction No 1 ____ Yes ____ No If your answer to question 3 is yes, then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. Was [name of defendant]'s conduct a substantial factor in causing harm to [name of plaintiff]? ____ 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. 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: $ $ $ $ $ ] ] ] ] ] VF-2504. Retaliation (Gov. Code, § 12940(h)) Instruction No 1 Request by Plaintiff Given as Proposed Refused Withdrawn Request by Defendant Given as Modified Requested by Given on Court's Motion Judge Instruction No 1 [b. Future economic loss [lost earnings [lost profits [medical expenses [other future economic loss $ $ $ $ ] ] ] ] ] ] ] Total Future Economic Damages: $ [c. [d. Past noneconomic loss, including [physical pain/mental suffering:] Future noneconomic loss, including [physical pain/mental suffering:] TOTAL Signed: _________________________ Presiding Juror $ $ $ 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, August 2007, December 2010, June 2013, December 2016