Independent Contractor Worksheet
This worksheet is designed to be compliant with the IRS rules regarding Independent Contractor (IC) determination
and as such must be completed by the hiring manager PRIOR to engaging any individual as an IC. If the “Primary
Test” is passed, no further preapproval is required and the manager may proceed with the engagement. If the
“Primary Test” is not passed, the manager should either: complete the secondary test and submit the full worksheet
to the Tax Manager for approval, OR contact HR for information on how to engage the worker as a Special
(Temporary) Hire instead of as an IC.
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Worker Name:
Department Requesting Determination:
Department Manager Name/Ext:
Proposed Start Date of Work:
State(s) in which work will be performed:
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Primary Test:
True False The worker has an established business (as evidenced by factors such as: a business tax
ID number, other clients/customers, advertising of services, own licenses/certificates
(as required), business/service liability insurance, etc.)
True False The work to be performed is unrelated to Middlebury’s educational mission (for
example: catering, snowplowing, auditing, etc.) and is related to the worker’s
established business (see above).
True False The proposed contractor has NOT otherwise been engaged as an employee by
Middlebury/MIIS is the same calendar year as the proposed IC work (this includes work
as a student employee).
True False The worker may perform services for other organizations while simultaneously
performing services for Middlebury.
True False The worker controls the means and methods of how the work is performed.
STOP:
If you responded True to ALL of the statements above, this individual can be retained as an Independent
Contractor without further review by the Tax Office. You may proceed with the engagement keeping in mind that
generally the Accounts Payable Dept. will require the following documentation in order to process payment: a
completed copy of the Primary Test (showing all “TRUE”), a signed contract (using an approved IC contract
template), invoice(s), W9, and a Certificate of Insurance. See the AP website for more information.
If you responded False to ANY of the statements, please complete the secondary test on the following pages and
submit the worksheet to the Tax Office for review, prior to finalizing an agreement with the worker.
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Secondary Test: (Please note that fields will expand as you type.)
Duties
1. Please describe the work the individual is being engaged to perform:
2. Where (in what state, and on whose premises) will the work be performed? Will Middlebury direct
where the work will be performed?
Behavioral Factors
1. Will the worker use his/her own tools and equipment (for example: computer equipment, catering
equipment, testing equipment, etc.) or Middlebury’s? Please describe.
2. Is the worker expected to personally do the work, or simply ensure that the work is done (that is, is
it acceptable for the worker to send one of his/her employees to perform the work)?
3. Does Middlebury retain the right to direct the manner in which the work is performed or only the
outcome/results? Please describe.
4. To what extent does Middlebury direct when the work will be done? (Due date only? Daily/weekly
scheduled hours? Other?)
5. Will Middlebury direct the order or sequence in which the work is to be performed? If so, please
elaborate.
6. Will the worker receive training from Middlebury in order to complete or perform the work for the
project? If so, please describe.
Financial Factors
1. To the extent necessary for the particular line of business, does the worker have a demonstrable
investment in his/her business (owns/leases equipment, office space, etc.)? Please describe.
2. To what extent does the worker make his/her services available to the marketplace (advertises,
actively solicits business, etc.)?
3. What is the proposed method of payment for the work (Flat rate based on bid? Hourly rate for all
hours worked? Monthly retainer? Other?)
4. Will Middlebury pay any of the worker’s business expenses? If yes, explain.
5. Will the worker bear the risk of making a profit or sustaining a loss under the work arrangement?
Type of Relationship Factors
1. To what extent are the services/work to be performed related to Middlebury’s regular business
(that is, education) and/or the same as the work performed by employees of Middlebury?
2. Does the manager propose to enter into a written contract for services (independent contractor
agreement) with the worker? Please attach draft of proposed contract, if available.
3. How long is the relationship expected to last?
4. Does Middlebury intend to provide the worker with any benefits (housing, meals, access to the
recreation facilities, other)? If so, please elaborate.
STOP:
Submit completed Worksheet to the Tax Office for approval PRIOR to engaging the worker as an IC.
You will be notified of the results of the status determination. If the request is approved you will be able to proceed
with the engagement, however keep in mind that generally the Accounts Payable Dept. will require the following
documentation (in addition to this approved worksheet) in order to process payment(s): a signed contract (using
an approved IC contract template), invoice(s), W9, and a Certificate of Insurance. See the AP website for additional
information.
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For TAX Office Use Only
Reviewed By:
Independent Contractor Status Approved:
Date
YES
NO