Name of Independent Contractor (if known)___________________________________

Social Security # /Federal Employer Id (if applicable)____________________________

Project Amount $ _____________________ Expected Start Date__________________

Department __________________________ Expected Termination Date ___________

Responsible University Project Manager ______________________________________

Telephone: _________________ FAX: _______________ E-MAIL: _______________

Specifications of Work: Describe the services to be provided by the above independent contractor/consultant.



The following criteria are general guidelines used by the IRS to determine whether or not an individual is functioning as an independent contractor/consultant. The fact that an individual is not now a University employee or that the work is short-term does not qualify the individual as an independent contractor/consultant. An individual (who is not doing business as a corporation or a legal partnership) who has been assigned a federal employer ID may not necessarily be considered as an independent contractor/consultant.

Answer the following questions by circling YES or NO
 1. Will a University employee direct the person providing this
 service as to when, where, and how to work?  YES NO
 2. Will the University control the sequence of the work? YES NO
 3. Will a University employee have responsibility for hiring,
 supervising or paying for any assistants to the project? YES NO
 4. Will work hours be set by the University? YES NO
 5. Is work to be performed on University property? YES NO
 6. Will tools and/or equipment be supplied by the University? YES NO
 7. Are payments to be made regularly (monthly, weekly)? YES NO
 8. Is compensation to be provided for travel or business
 expenses? YES NO
 9. Will the individual provide materials and supplies for
 the job? YES NO
10. Will the individual have an investment or share in the
 profit/loss of the job?  YES NO
11. Will the individual do same work for other companies 
outside the University? YES NO
12. Does the individual have employees of his/her own? YES NO
13. Does the University have the right to discharge the
 worker?  YES NO

Additional comments/explanation:___________________________________________ _______________________________________________________________________ _______________________________________________________________________

 ______________________________ ____________________
 Office of Human Resources Date


The Purchasing Department will need the following, in addition to this approved form, to complete this process and facilitate payment.

The Independent Personal Service Contract (available from Central Supply), completed by the department and signed by the contractor/consultant.

A Requisition for Purchase Form or electronic requisition completed and authorized by the department.

OHR 4/95


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Last modified August 15, 2002