VF-2509. Disability Discrimination--Reasonable Accommodation (Gov. Code, � 12940(m)) Instruction No 1 Request by Plaintiff Given as Proposed Refused Withdrawn Request by Defendant Given as Modified Requested by Given on Court's Motion Judge Instruction No 1 We answer the questions submitted to us as follows: 1.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 defendant] [an employer/[other covered entity]]? ____ 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 plaintiff] [an employee of [name of defendant]/an applicant to [name of defendant] for a job/[other covered relationship to defendant]]? ____ 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. Did [name of plaintiff] have [a] [select term to describe basis of limitations, e.g., physical condition] [that limited [insert major life activity]]? ____ 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-2509. Disability Discrimination--Reasonable Accommodation (Gov. Code, � 12940(m)) Instruction No 1 Request by Plaintiff Given as Proposed Refused Withdrawn Request by Defendant Given as Modified Requested by Given on Court's Motion Judge Instruction No 1 presiding juror sign and date this form. 4. Did [name of defendant] know of [name of plaintiff]'s [e.g., physical condition] [that limited [insert major life activity]]? ____ 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 plaintiff] able to perform the essential job duties with reasonable accommodation for [his/her] [e.g., physical condition]? ____ 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 defendant] fail to provide reasonable accommodation for [name of plaintiff]'s [e.g., physical condition]? ____ Yes ____ No If your answer to question 6 is yes, then answer question 7. If you answered no, stop here, answer no further questions, and have the presiding juror sign and date this form. VF-2509. Disability Discrimination--Reasonable Accommodation (Gov. Code, � 12940(m)) 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 7. Was [name of defendant]'s failure to provide reasonable accommodation a substantial factor in causing harm to [name of plaintiff]? ____ Yes ____ No If your answer to question 7 is yes, then answer question 8. If you answered no, stop here, answer no further questions, and have the presiding juror sign and date this form. 8. 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 $ $ ] ] $ $ $ $ $ ] ] ] ] ] VF-2509. Disability Discrimination--Reasonable Accommodation (Gov. Code, � 12940(m)) 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 [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 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, April 2009, December 2009, December 2010, December 2016