ROGERS STATE UNIVERSITY
REQUEST FOR INDEPENDENT CONTRACTOR APPROVAL
This form should be completed by the contracting University department in consultation with the worker/service provider,
approval obtained and a contract executed before any services are provided. Do not complete this form for an employee
currently working or who has worked as an employee within the last year for Rogers State University. If the worker is
currently appointed on the payroll or has worked as an employee for the university within the past year, you must pay
them by special pay through the Payroll and Employment & Benefits Office.
INFORMATION ABOUT SERVICE PROVIDER:
Individual Sole Proprietor
Name: Social Security Number:
Name of Company:
Department where work will be performed:
Please describe services to be provided:
Dates and Length of time services will be provided this fiscal year:
Please answer the following questions based on the IRS Classification Factors:
Instructions: Will the service provider receive instructions not only on when, and where, but
on how the work results are to be achieved?
Training: Will the service provider receive specific training from the University to perform the
Integration: Are the services performed for the university consistent with the type of services
generally performed by the service provider?
Personally rendered services: Can the service provider send substitutes to perform the work
if he/she desires?
Hiring, supervision, or payment of assistants: Will the service provider have the right to hire
and supervise others to assist in completion of the contracted work, where said assistants’
compensation is the responsibility of the service provider?
Continuing relationship: Does the service provider work at sporadic intervals under specific
job completion dates?
Set hours of work: Will the service provider set his/her own hours to perform the contracted
Full-time effort: Does or will the service provider perform like or similar services for
organizations other than the university?
Work done on employer’s premises: Will the service provider perform or execute duties
entirely on university premises?
Order or sequence set: Will the service provider be able to exercise some discretion on the
order in which work is done?