VF 4600. False Claims Act Whistleblower Protection (Gov. Code, § 12653)

VF-4600. False Claims Act: Whistleblower Protection (Gov. Code, § 12653) Instruction No 1 Request by Plaintiff Given as Proposed Refused Withdrawn Request by Defendant Given as Modified Requested by Given on Court's Motion Judge Instruction No 1 We answer the questions submitted to us as follows: 1.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 plaintiff] [specify acts done in furthering the false claims action or to stop a false claim]? ____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] act [in furtherance of a false claims action/to stop a false claim]? ____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. Did [name of defendant] [discharge/specify other adverse action] [name of plaintiff]? VF-4600. False Claims Act: Whistleblower Protection (Gov. Code, § 12653) Instruction No 1 Request by Plaintiff Given as Proposed Refused Withdrawn Request by Defendant Given as Modified Requested by Given on Court's Motion Judge Instruction No 1 ____Yes ____No If your answer to question 4 is yes, then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. Were [name of plaintiff]'s acts [in furtherance of a false claims action/to stop a false claim] a substantial motivating reason for [name of defendant]'s decision to [discharge/other adverse 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. Was [name of defendant]'s conduct a substantial factor in causing harm to [name of plaintiff]? ____ 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. 7. What are [name of plaintiff]'s damages? [a. Past economic loss [lost earnings $ ] VF-4600. False Claims Act: Whistleblower Protection (Gov. Code, § 12653) 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 [lost profits [medical expenses [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: VF-4600. False Claims Act: Whistleblower Protection (Gov. Code, § 12653) 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 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 2015; Revised December 2016