DETERMINATION OF INDEPENDENT CONTRACTOR WORKSHEET
Complete only if contracting with an individual or sole proprietorship. If you are hiring an individual or
sole proprietor, it is important to establish that the nature of the service does not constitute an
employee/employer relationship. The following factors are critical and may be enough to establish
independent contractor status.
If the answer to any of the following questions is “YES”, you may need to consider hiring the individual
as an employee. The more “YES” responses there are, the more likely it is that the individual should be
hired as an employee. Fill in the form completely; no questions should be left unanswered.
When contracting with an individual or sole proprietorship, this form must be routed with the
Agreement to the Procurement Office.
Payee
Name_____________________________________________
Address______________________________________________
City, State, Zip__________________________________________
Da
te:_____________
Ph
one:___________
Date:_____________
Prepared by:__________________________________________
Department Name:_____________________________________
Department Signature__________________________________
REV 10/2019
Individual
Sole Proprietor
SSN_______________________
1. Is the individual an employee of the State of West Virginia?.........................Yes No
2. Is the individual working exclusively for Fairmont State University?..............Yes No
3. Are the services of the individual integrated into your organization?
EX: Are you hiring
him/her to teach for credit?.............................................Yes No
4. Are you providing any assistance to the individual such as
work space, supplies, equipment, etc.?............................................................Yes No
5. Are you providing on-going training and direction concerning how
to complete the task? EX: are you giving more than general directions
and the task objective?.....................................................................................Yes No
6. Does the individual report to a FSU staff member who has the right
to change HOW or WHEN the individual does their work?..............................Yes No
7. Is there a regular or on-going relationship with the individual? Has
the individual received a payroll check in the past year for employment
in any university department?..........................................................................Yes No
8. Is the individual using experience or expertise gained as a current
or previous FSU employee to provide the service?..........................................Yes No
9. Can the individual quit prior to completion of the project without
incurring any legal liabillity?..............................................................................Yes No
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signature
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