(Full Court Heading)

SPECIAL VERDICT

SECTION I

        You must answer all questions in this section.

        QUESTION NO. 1. Was defendant (name) negligent in connection with the (product name)?

         ANSWER: Yes_____ No_____

        QUESTION NO. 2. Was the (product name) manufactured [or sold] by defendant (name) in a defective condition unreasonably dangerous to person or property?

        ANSWER: Yes_____ No_____

        QUESTION NO. 3. Did defendant (name) breach any express warranties in connection with the (product name)?

        ANSWER: Yes_____ No_____

        QUESTION NO. 4. Did defendant (name) breach any implied warranty of merchantability in connection with the (product name)? ANSWER: Yes_____ No_____

        QUESTION NO. 5. Did defendant (name) breach any implied warranty of fitness for a particular purpose in connection with the (product name)? 

        ANSWER: Yes_____ No_____

        If you answered "No" to each question in this section, then sign the verdict form and inform the bailiff that you are done. If you answered "Yes" to one or more of the questions in this section, you must answer all of the other questions to which the form directs you.

SECTION II

        You must answer Question No. 6 in this section only if you answered "Yes" to one or more of Question Nos. 1 through 5 of Section I.

        QUESTION NO. 6. Did defendant (name) exercise reasonable care in his sale of the product? 

        ANSWER: Yes_____ No_____

        If you answered "Yes" to this question, then sign the verdict form and inform the bailiff that you are done. If you answered "No" to this question, you must answer all of the other questions to which the form directs you.

SECTION III

        You must answer Question No. 7 in this section only if you answered "Yes" to either Question Nos. 4 or 5 of Section I.

        QUESTION NO. 7. Did plaintiff (name) fail to examine the product? 

        ANSWER: Yes_____ No_____

        You must answer all of the other questions to which the form directs you.

SECTION IV

        You must answer only those questions in this section to which you are directed by the instructions in this section. You should not answer any questions to which you are not directed. You must answer Question No. 8 only if you answered Question No. 1 "Yes" and Question No. 6 "No."

        QUESTION NO. 8. Was the negligence of defendant (name) a proximate cause of the accident? 

        ANSWER: Yes_____ No_____

        You must answer Question No. 9 only if you answered Question No. 2 "Yes" and Question No. 6 "No."

        QUESTION NO. 9. Was the unreasonably dangerous defective condition of the (product name) a proximate cause of the accident? 

        ANSWER: Yes_____ No_____

        You must answer Question No. 10 only if you answered Question No. 3 "Yes" and Question No. 6 "No."

        QUESTION NO. 10. Was the breach of express warranty by defendant (name) a proximate cause of the accident?

        ANSWER: Yes_____ No_____

        You must answer Question No. 11 only if you answered Question No. 4 "Yes" and Question Nos. 6 and 7 "No."

        QUESTION NO. 11. Was the breach of implied warranty of merchantability by defendant (name) a proximate cause of the accident? 

        ANSWER: Yes_____ No_____

        You must answer Question No. 12 only if you answered Question No. 5 "Yes" and Question Nos. 6 and 7 "No."

        QUESTION NO. 12. Was the breach of implied warranty of fitness for a particular purpose a proximate cause of the accident? 

        ANSWER: Yes_____ No_____

        If you answered "No" to each question in this section to which you were directed by the form, then sign the verdict form and inform the bailiff that you are done. If you answered "Yes" to one or more of the questions in this section to which you were directed, you must answer all of the other questions to which the form directs you.

SECTION V

        You will answer the questions in this section only if you answered "Yes" to one or more of Question Nos. 8, 9, 10, 11 and 12. If you answered "No" to all those questions to which you were directed, you should not answer any of the questions in this section.

        QUESTION NO. 13. Did plaintiff (name) misuse the (product name)?

        ANSWER: Yes_____ No_____

        If you answered Question No. 13 "Yes," then please answer Question No. 14. If you answered Question No. 13 "No," then you will not answer Question No. 14, but will next answer Question No. 15.

        QUESTION NO. 14. Was the misuse of the product by plaintiff (name) a proximate cause of the accident?

        ANSWER: Yes_____ No_____

        QUESTION NO. 15. Did plaintiff (name) assume the risk of the accident?

        ANSWER: Yes_____ No_____

        If you answered Question No. 15 "Yes," then please answer Question No. 16. If you answered Question No. 15 "No," then you will not answer Question No. 16, but will next answer Question No. 17.

        QUESTION NO. 16. Was the assumption of the risk by plaintiff (name) a proximate cause of the accident?

        ANSWER: Yes_____ No_____

        QUESTION NO. 17. Was the (product name) altered by plaintiff (name) after it left the hands of defendant (name)?

        ANSWER: Yes_____ No_____

        If you answered Question No. 17 "Yes," then please answer Question No. 18. If you answered Question No. 17 "No," then you will not answer Question No. 18, but will next answer Question No. 19.

        QUESTION NO. 18. Was the alteration of the product a proximate cause of the accident? ANSWER: Yes_____ No_____

        QUESTION NO. 19. Did plaintiff (name) fail to observe the condition which injured him? 

        ANSWER: Yes_____ No_____

        If you answered Question No. 19 "Yes," then please answer Question No. 20. If you answered Question No. 19 "No," then you will not answer Question No. 20, but will go on to Section VI.

        QUESTION NO. 20. Was the failure to observe by plaintiff (name) a proximate cause of the accident?

        ANSWER: Yes_____ No_____

SECTION VI

        You will answer Question No. 21 of this section only if you answered one or more of Question Nos. 14, 16, 18 and 20 "Yes." If you answered all of those questions "No," then you will not answer Question No. 21, but will next answer Question No. 22.

        QUESTION NO. 21. We find that the parties contributed to the cause of the accident in the following percentages:

            (a)    The plaintiff (name)         _____%

            (b)    The defendant (name)    _____%

                                Total                     100 %

        If the percentage of causation for the plaintiff is 50% or more, then you will not answer Question No. 22, but will simply sign the verdict form and inform the bailiff that you are done.

        If the percentage of causation for the plaintiff is less than 50%, you will then answer Question No. 22.

        QUESTION NO. 22. What is the total amount of damages sustained by the plaintiff (name) as a result of the accident?

        ANSWER: $__________.

                                        Foreman

                                        (11 signature lines)