ࡱ> PRO bjbj 48Ix---8el-\.lYoooJJJ$,JJoo___poo____oZfP- F_,0\_O__hJ0z"_JJJdJJJ\JJJJJJJJJ : This Form includes questions that must be answered to obtain FS-Payrolls consideration of a request to pay an individual as an independent contractor paid by UMB, rather than to pay the individual as an employee. The questions relate to factors under the common law employment test. Information not requested by the Form may be provided on attachments if relevant to the factors. Name: _________________________________ Department: ______________________________ Employee or Independent Contractor Evaluation Factors: Please answer yes or no where requested. No answers suggest that independent contractor status may not be correct. On attachments, please explain no answers, and please explain any cases when circling both Yes and No was necessary. 1. The individuals work will be performed off campus:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Location of work: _________________________ 2. The individual will choose the methods used to perform the work.  FORMCHECKBOX  Yes  FORMCHECKBOX  No 3. The individual will be supervised in doing the work.  FORMCHECKBOX  Yes  FORMCHECKBOX  No 4. The individual will set her own daily hours of work.  FORMCHECKBOX  Yes  FORMCHECKBOX  No 5. The individual offers services to the general public, and does not receive a majority of her income from UMB.  FORMCHECKBOX  Yes  FORMCHECKBOX  No 6. The individual will not be receiving training from UMB in order to be able to perform the work.  FORMCHECKBOX  Yes  FORMCHECKBOX  No 7. The individual did not do work of the same type while employed by UMB prior to retirement or other separation from service.  FORMCHECKBOX  Yes  FORMCHECKBOX  No 8. The individual will not be supervising or teaching students.  FORMCHECKBOX  Yes  FORMCHECKBOX  No 9. The individual has a significant investment in facilities, equipment and tools needed for the work, and will not rely exclusively or primarily on UMB facilities, equipment and tools.  FORMCHECKBOX  Yes  FORMCHECKBOX  No 10. The work is episodic, not regular or recurring. Completion of the work is defined. The individual will be liable for breach of contract if he does not complete the work.  FORMCHECKBOX  Yes  FORMCHECKBOX  No 11. Any assistants required by the individual will be hired, supervised and controlled by the individual. The University has no right to require that any assistant be hired or fired.  FORMCHECKBOX  Yes  FORMCHECKBOX  No 12. The individual is not obligated to provide substantially full-time work for the University, and is free to work when, and for whatever firms or universities, he chooses.  FORMCHECKBOX  Yes  FORMCHECKBOX  No 13. The individual will be paid by the job or on a lump sum basis, and will not receive any employment benefits or compensation determined as the value of employment benefits.  FORMCHECKBOX  Yes  FORMCHECKBOX  No 14. The individual will be, or may be, engaged as a contractor providing services to more than one firm or university while engaged by UMB.  FORMCHECKBOX  Yes  FORMCHECKBOX  No 15. The individual is prepared to sign a contract issued through Procurement Services, and will be liable for breach of contract if he or she stops providing services without completing the work.  FORMCHECKBOX  Yes  FORMCHECKBOX  No     Independent Contractor Determination Form 챬, Baltimore Page  PAGE 1         ! 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