INDEPENDENT CONTRACTOR CHECKLIST FORM
Part 1 Service Provider/Name:
Description of services being performed:
Is This Person a Current or Former FGCU Employee: No ☐
N#
Yes ☐ *(See Below)
Dept.:
Part 2 IRS Common Law Guidelines
Behavioral control: (Check all that apply)
1. Will FGCU provide instruction about when, where, and how this
work will be done?
2. Will FGCU provide training to the individual?
3. Will FGCU require the individual to perform the services
personally?
4. Will FGCU establish the hours of work?
5. Will FGCU require the services full-time during the duration of the
contract?
6. Will the work be performed on FGCU premises?
Index:
YES
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Employee Classification
Complies with the unit’s
instructions.
NO
Trained by FGCU.
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Must be performed
personally.
FGCU sets the hours.
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FGCU requires full-time
commitment.
Performed at FGCU.
7. Will FGCU require reports on a regular basis?
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FGCU requires reports.
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Financial Control (Check all that apply)
8. Will the pay be based on hourly, weekly, or monthly rate?
YES
NO
9. Will FGCU pay the worker’s business and/or traveling expenses?
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10. Will FGCU furnish equipment, material, tools, and/or supplies?
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11. Is the service provider’s office in a home?
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Employee Classification
FGCU pays on an hourly,
weekly, or monthly basis.
FGCU pays the business
and traveling expenses.
FGCU furnishes
equipment, material,
tools, and/or supplies.
Works at home.
Relationship (Check all that apply)
12. Does the service provider work for one firm at a time?
YES
NO
13. Does the service provider make his/her services known to the
public primarily through word of mouth?
14. Does FGCU have the right to discharge the worker?
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15. Does the individual have the right to end his/her relationship with
FGCU at any time without incurring liability?
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Employee Classification
Works for one firm at a
time.
Makes his/her services
known by word of mouth.
FGCU has the right to
discharge.
The individual can
terminate at any time.
16. Does FGCU anticipate continuing relationship?
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FGCU anticipate
continuing relationship.
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17. Will you integrate the worker’s service into your daily operations
by providing email, an office, and requiring attendance at meetings?
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Integrated into unit.
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Independent Contractor Classification
Determines own schedule, location, and
task.
Responsible for own training.
Can be performed by his/her employees or
subcontractors.
Responsible for his/her own schedule.
Can work with others during period of the
contract.
Performed at the individual’s place of
business.
Reports are not required unless stipulated
in contract.
Independent Contractor Classification
FGCU pays per projects.
Responsible for all expenses and can
maximize profit by managing costs.
Individual furnishes everything.
Rents office space at fair market value
from an unrelated party and/or has
employees as a workforce for his/her
projects. Has significant investment in
business.
Independent Contractor Classification
Performs services for multiple unrelated
customers at the same time.
Advertises his/her business in
publications, yellow pages, web, etc.
Cannot be fired if he/she produces a result
based on the specifications of the contract.
The service provider incurs liability for
non-delivery.
A continuing relationship is not
anticipated. Projects will be awarded only
when the need arises, and will be based on
bids and specifications.
Independent of until activities.
Part 3
Evaluation and Certification
Purchasing/Accounts Payable will have the final determination of status based on answers provided to checklist and must be approved prior to executing
of contract.
I acknowledge that Florida Gulf Coast University may hold my unit financially responsible for any taxes, interest, or penalties the Internal Revenue Service or
other regulatory bodies might assess due to misclassification.
Signature:
Printed Name:
Dean/Director/Dept. Head
Phone:
Email:
Date:
*Yes: Independent Contractor Status is not appropriate. The individual must be hired as an OPS Employee through the Department of
Human Resources. Contact Human Resources for sign-on information.
02/28/2013