Independent Contractor or Employee Determination Form
Instructions: As required under University Policy 20.1.17, this form must be completed for the engagement of professional service providers. The completed form (including all signatures must be attached to the requisition in RIAS.
To be completed by Service Provider
Name of Individual/ Business
Street Address
City, State, and ZIP code
Explain in detail the nature of the service to be provided.
1. Are you a current employee or have you been a Rutgers employee during the past twelve (12) months? If you answer “YES”, DO NOT complete the remainder of this form. The payment MUST be paid through Payroll.
2. Are you a single-member LLC? If you answer “YES”, DO NOT complete the remainder of this form. The payment MUST be paid through Payroll.
3. How many full time employees are in your company? # ______
4. Are you required to comply with instruction about how the work is to be performed? YES NO
5. Are you being trained by Rutgers to perform the services? YES NO
6. Does Rutgers hire, supervise and pay assistants to help you with the services provided? YES NO
7. Are the services being provided to Rutgers on a continuing (frequent or long-term) basis? YES NO
8. Does Rutgers set your work schedule, i.e. the number of hours to be worked and when? YES NO
9. Do you market your services to the general public YES NO
10. Are you free to provide services for other entities? YES NO
11. Does Rutgers provide the tools, materials and supplies necessary to complete the work? YES NO
12. Can Rutgers discharge you for reasons other than non-performance of the contract? YES NO
13. Provide the current names of your three (3) major clients other than Rutgers
(If preferred, client list may be attached separately)
Client: / Client: / Client:Contact: / Contact: / Contact:
Phone: / Phone: / Phone:
Email: / Email: / Email:
I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE ALL OF THE ABOVE QUESTIONS HAVE BEEN ANSWERED CORRECTLY.
SIGNATURE OF INDIVIDUAL OR COMPANY OFFICIAL AND TITLE DATE
By submitting this form, you certify that all information provided is accurate and reliable; your company is not suspended or debarred by the Federal Government or the State of New Jersey from participating in Federal or State funded projects; have not been sanctioned by or excluded from participation in any federal or state health care program, including Medicare and Medicaid; and that no conflict of interest exists or will exist as a result of your participation as a Rutgers supplier (Conflict of Interest: http://purchasing.rutgers.edu/NoticetoVendors%20final.pdf).
Independent Contractor or Employee Determination Form
To be completed by Department
1. Explain the need for the professional service provider and include the reason(s) why these services could not be provided by present University employees.
2. Describe the qualifications of this professional service provider to perform the services in question 1 and the process by which this individual was selected over any other qualified individuals.
3. Is the Professional Service Provider a current or former federal, state, and/or local elected or appointed government official? Former public officials are defined as those who have held office or other public positions within three years of their Rutgers employment or engagement. (Yes or No) If yes, please complete the Employment of Current and Former Public Officials form located at http://rias.rutgers.edu/formsrequirements.html
4. If the services are less than $5,000, please provide how you determined the reasonableness of the fees being charged by the Professional Service Provider. (For purchases over $5000, please complete a Sole/Single Source Justification form if the services were not bid.)
5. Rutgers designates ______as the Project Director to whom the professional service provider shall from time to time submit reports on the time dedicated to the services and the progress. The Project Director is responsible for monitoring the quality of the services delivered by the professional service provider. All work shall be undertaken and completed no later than the agreed upon date.
6. Specify how the Project Director will monitor the quality of the service provided.
PLEASE PRINT
REQUESTERS NAME: ______DIRECTOR OR DEPARTMENT HEAD:
DEPARTMENT: ______NAME: ______
EMAIL ADDRESS: ______EMAIL ADDRESS: ______
DATE: ______DATE: ______
SIGNATURE: SIGNATURE:
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