VF-2514. Failure to Prevent Harassment, Discrimination, or Retaliation Instruction No 1 Request by Plaintiff Given as Proposed Refused Withdrawn Request by Defendant Given as Modified Requested by Given on Court's Motion Judge Instruction No 1 We answer the questions submitted to us as follows: 1.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] fail to take all reasonable steps to prevent the [harassment/discrimination/retaliation] ____ 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 failure to prevent the [harassment/discrimination/retaliation] a substantial factor in causing harm to [name of plaintiff]? ____ 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. What are [name of plaintiff]'s damages? [a. Past economic loss [lost earnings [lost profits [medical expenses $ $ $ ] ] ] VF-2514. Failure to Prevent Harassment, Discrimination, or Retaliation Instruction No 1 Request by Plaintiff Given as Proposed Refused Withdrawn Request by Defendant Given as Modified Requested by Given on Court's Motion Judge Instruction No 1 [other past economic loss Total Past Economic Damages: [b.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. [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 VF-2514. Failure to Prevent Harassment, Discrimination, or Retaliation Instruction No 1 Request by Plaintiff Given as Proposed Refused Withdrawn Request by Defendant Given as Modified Requested by Given on Court's Motion Judge Instruction No 1 [clerk/bailiff/court attendant] that you are ready to present your verdict in the courtroom. __________________________________________________________________________ New June 2010; Revised December 2010, June 2013, December 2016