VF-2515. Limitation on RemediesSame Decision Instruction No 1 Request by Plaintiff Given as Proposed Refused Withdrawn Request by Defendant Given as Modified Requested by Given on Court's Motion Judge Instruction No 1 We answer the questions submitted to us as follows: 1.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 defendant] [discharge/refuse to hire/[other adverse employment action]] [name of plaintiff]? ____ 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 plaintiff]'s [protected status or activity] a substantial motivating reason for [name of defendant]'s [discharge of/refusal to VF-2515. Limitation on RemediesSame Decision Instruction No 1 Request by Plaintiff Given as Proposed Refused Withdrawn Request by Defendant Given as Modified Requested by Given on Court's Motion Judge Instruction No 1 hire/[other adverse employment action]] [name of plaintiff]?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. Was [specify employer's stated legitimate reason, e.g., plaintiff's poor job performance] also a substantial motivating reason for [name of defendant]'s [discharge of/refusal to hire/[other adverse employment action]]? ____ 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. Would [name of defendant] have [discharged/refused to hire/[other adverse employment action]] [name of plaintiff] anyway at that time based on [e.g., plaintiff's poor job performance] had [name of defendant] not also been substantially motivated by [discrimination/retaliation]? ____ Yes ____ No If your answer to question 6 is no, then answer question 7. If you answered yes, stop here, answer no further questions, and have the presiding juror sign and date this form. 7. Was [name of defendant]'s [discharge/refusal to hire/[other adverse VF-2515. Limitation on RemediesSame Decision 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 employment action]] 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 [medical expenses $ $ $ ] ] ] $ $ $ $ $ ] ] ] ] ] VF-2515. Limitation on RemediesSame Decision 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 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 December 2013; Revised December 2015, December 2016