Contractor Status Questionnaire

All of the questions must be answered.  As necessary, use additional sheets of paper to fully present the circumstances.

 1) Describe the nature of the services to be provided:

 2) Where are the services performed?

 3) Does the individual have a business location and phone?        Yes __ No ____

 4) Does the individual have a tax identification number,
     other than a  Social Security Number?                                           Yes ____ No ____

5) Does the individual provide the same or similar services to others?                Yes ____ No ____

6) Does the individual provide services:

                        a) In UC’s name?                                              Yes ____ No ____                       
                        b) In the individual’s own business name? Yes ____ No ____
                        c) Other (explain)                                             Yes ____ No ____

7) Will the individual be provided training?                      Yes ____ No ____  

            If yes, describe:    a) What kind:

                                            b) How often:

 8) Will the individual be instructed in the manner in
     which the work   is to be performed?                               Yes ____ No ____

           If yes, give an example:

9) Will the individual be supervised or controlled in
    the performance of the work?                                           Yes ____ No ____

          If yes, give an example:

10) Is this individual engaged to perform and
      complete a particular job?                                               Yes ____ No ____

             If no, please explain:

 11) Does the individual provide reports?

a)    How often________________________________________________________

b)      For what purpose   _______________________________________________

c)      In what manner  __________________________________________________

d)      To whom  _______________________________________________________

12)  Does the individual furnish a time record?                  Yes ____ No ____

 If yes, how often ___________________         

 13) Type of compensation:

             Salary ____ Commission ____ Hourly ____ Lump sum ____

 14) How long and how often does the individual perform services? (hours & days)

             _________________________________________________________________

 15) Are there other workers in the department
      providing the same or similar services?                              Yes ____ No ____

            If yes, how many? ______                                                                                               

Are they UC employees?                                                  Yes ____ No ____

 16) Has this individual performed services under a
       personal service contract with UC in the last 18 months?Yes____ No ____

             If yes, please attach copies of the contracts.

 Certified as accurate to the best of my knowledge.

Unit Head, Director or Dean _______________________________________ Date __________________