Employee/Independent Contractor Determination Checklist Form

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Employee/Independent Contractor Determination Checklist Form

The checklist must be completed to assist the Office of Human Resources (OHR) in determining whether an employer relationship exists for Federal Insurance Contributions Act (FICA) tax purposes. The questions will provide information as to the degree of control and the degree of independence in the relationship between the individual performing services and NCCU, although additional information may be requested to make the appropriate determination. Final determination is made by Human Resources and is based on consideration of all the known facts and not any one answer alone.

This determination checklist must be completed to assist Human Resources in determining whether an employer/employee relationship exists for federal, state and FICA tax purposes. The questions below will provide information as to the degree of control and the degree of independence in the relationship between the individual performing services and NCCU, although additional information may be requested to make the appropriate determination. Final determination is made by Human Resources and is based on consideration of all the known facts and not any one answer alone.

Sections I and II may be completed by the originating department or by the individual performing the service.
Section II requires only one part (A, B, or C) to be completed.

Part A is for guest lecturers.
Part B is for high-level researchers such as co-principal investigators on sponsored projects.
Part C is for all other individuals.

Section III requires the individual performing services signature before submitting to the department representative.

Section IV must be fully completed and signed by the department representative.

Section V contains questions regarding the 20-factor test for determining independent contractor or employee status as described in detail. (Refer to Section IV to answer the checklist questions.)

Section VI certifies the appropriate NCCU department and representative are authorizing the service being performed.

First Name

Last Name

Service Provider’s Name

Service Provider’s Mailing Address

City

State

Zip

Department Representative Name

Department Representative Email

Section III – Certification of Service Provider

I certify that the information provided in this document is correct.

Name of the Individual Performing Services

Date

Department Representative Email

HR Email

Human Resources Approval

Human Resources Status

Human Resources Comment/Notes

Human Resources Signature

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Employee/Independent Contractor Determination Checklist Form

Employee/Independent Contractor Determination Checklist Form

Section I - Current Employer/Employee Relationship

Section II - Complete Only One Part (A, B, or C)

Section III – Certification of Service Provider

Section IV – Description of Services

Section V - Checklist for Determination of Independent Contractor (IC) or Employee Status

Interview Planning Checklist Items

Comments

Independent Contractor

Comments

Section VI – Certification of NCCU Department

Human Resources Approval