VF-2505. Quid pro quo Sexual Harassment Instruction No 1 Request by Plaintiff Given as Proposed Refused Withdrawn Request by Defendant Given as Modified Requested by Given on Court's Motion Judge Instruction No 1 We answer the questions submitted to us as follows: 1. Was [name of plaintiff] an employee of [name of defendant]? ____ 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 alleged harasser] make unwanted sexual advances to [name of plaintiff] or engage in other unwanted verbal or physical conduct of a sexual nature? ____ 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. Were terms of employment, job benefits, or favorable working conditions made contingent on [name of plaintiff]'s acceptance of [name of alleged harasser]'s sexual advances or conduct? ____ 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-2505. Quid pro quo Sexual Harassment Instruction No 1 Request by Plaintiff Given as Proposed Refused Withdrawn Request by Defendant Given as Modified Requested by Given on Court's Motion Judge Instruction No 1 4. At the time of [his/her] conduct, was [name of alleged harasser] a supervisor or agent for [name of defendant]? ____ 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 alleged harasser]'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 [other past economic loss $ $ $ $ ] ] ] ] VF-2505. Quid pro quo Sexual Harassment Instruction No 1 Request by Plaintiff Given as Proposed Refused Withdrawn Request by Defendant Given as Modified Requested by Given on Court's Motion Judge Instruction No 1 Total Past Economic Damages: [b. Future economic loss [lost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 VF-2505. Quid pro quo Sexual Harassment 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 courtroom. ___________________________________________________________________________ New September 2003; Revised April 2007, December 2010, December 2015, December 2016